LIBRARY 

OF  THE 

UNIVERSITY  OF  CALIFORNIA. 

GIFT    OF 


Class 


; 


MEDICAL 


EXAMINATIONS 


LIFE    INSURANCE. 


J.  ADAMS  ALLEN,  M.D.  LL.  D., 

D  PRACTICE  OF  MEDICINE  AND  CLINICAL  MBDICINB  IN  RUSH  M 
PROF.  PHYSIOLOGY  AND  PATHOLOGY  IN  THB  UNIVERSITY  OF  Mi 


EIGHTH    EDITION: 

REVISED  AND    ENLARGED, 

With  new  Introductory  Chapter  ami  an  Extensive  Appendix, 


NEW  YORK  AND  CHICAGO 

THE    SPECTATOR   COMPANY, 

PUBLISHERS, 

1886. 


Entered  according  to  Act  of  Congress,  in  the  year  iSSo, 

By  THE  SPECTATOR  COMPANY, 
In  the  office  of  the  Librarian  of  Congress,  Washington,  D.  C. 


THE  SPECTATOR  PRESS, 
JVo.  16  Dey  Street,  New  York. 


PREFACE  TO   EIGHTH    EDITION. 


The  exhaustion  of  six  editions  of  this  brief  manual  within  a  few 
months,  sufficiently  demonstrates  the  want  which  has  been  felt  foi 
some  work  of  the  character.  The  Author  tenders  his  sincere  acknowl- 
edgements for  the  kindly  terms  in.  which  many  of  the  most  distin- 
guished  Medical  Examiners  throughout  the  country  have  been  pleased 
to  welcome  its  publication.  He  is  fully  sensible  of  the  difficulties 
necessarily  incident  to  the  effort  to  take  an  intermediate  course  be- 
'ween  the  voluminous  and  elaborate  treatise  and  the  mere  tractate. 

rhis  little  book  is  published  as  a  chart,  and  not  as  an  exhaustive 
Tolume. 

The  effort  has  been  to  bring  fairly  before  the  Medical  Exarrine/ 
the  salient  points  of  his  business,  in  as  concise  a  form  as  perspicuity 
would  possibly  permit 

In  the  present  edition  there  has  been  but  little  change,  save  in  the 
addition  of  an  Appendix  containing  matter,  which,  it  is  believed, 
will  add  considerably  to  the  value  of  the  work,  and  also  an  Intro- 
ductory Chapter,  calling  the  especial  attention  of  Examiners  to  th" 
importance  of  the  relations  they  sustain  to  their  respective  Companies  ; 
to  the  parties  examined,  and  to  the  profession. 

Attention  is  called  to  the  Index  of  the  Appendix,  on  page  169, 
which  indicates  the  general  character  of  the  additions  made.  The 
contained  tables  are  believed  to  be  valuable. 


219828 


!v 

In  the  preparation  of  these  additions,  the  Author  begs  leave  to 
acknowledge  the  important  services  of  I.  N.  DANFORTH,  M.  D.,  of 
this  city — not  only  a  medical  examiner  of  large  experience,  but  an 
accomplished  professional  scholar  and  writer. 

Under  the  pressure  of  his  own  multitudinous  affairs,  the  Author  has 
delayed  publication  of  a  new  edition  until  the  previous  one  was  long 
out  of  print.  Advantage  has  been  taken  of  this  delay  to  seek  for  the 
opinions  and  suggestions  of  professional  Life  Insurance  men,  both  lay 
and  professional.  These  have  been  regarded  in  this  edition,  so  far 
as  they  have  appeared  correct  and  feasible. 

In  order  not  to  make  the  volume  too  bulky,  the  Appendix  and 
IntrDductory  chapters  have  been  given  in  smaller  type  than  used  in 
the  text.  j.  A.  A. 


INTRODUCTION 


It  is  now  about  one  hundred  and  fifty  years  since  life  insurance  first 
established  itself  on  anything  like  an  enduring  basis.  Commencing  with 
the  "Amicable  Society,"  of  London,  it  has  steadily  grown  in  public 
favor  until,  at  the  present  day,  no  form  of  investment  is  regarded  with 
greater  favor,  by  even  the  shrewdest  and  most  sagacious  business  men, 
than  the  stocks  of  life  insurance  companies,  and  policies  of  insurance  on 
their  own  lives.  At  every  step  of  its  progress,  this  noble  institution  has 
sought  the  aid  and  counsel  of  the  medical  profession.  It  has  its  very 
basis  and  foundatiotn,  in  fact,  in  the  established  laws  of  mortality,  as 
carefully  and  patiently  worked  out  by  medical  men.  The  first  life  com- 
pany was  only  started  after  Dr.  Halley,  of  London,  had  made  that 
series  of  observations  regarding  the  duration  of  human  life,  out  of 
which  grew  the  "  Breslau  table  of  mortality."  Every  important  step  in 
life  insurance  has  been  preceded  by  a  pioneer  corps  of  physicians,  who 
have  carefully  marked  out  the  way ;  and,  in  no  single  instance,  has  fu- 
ture experience  proved  the  falsity  or  unreliability  of  their  conclusions. 

If  all  this  be  true,  it  follows  that  the  relations  of  the  medical  profes- 
sion to  the  interests  of  life  insurance  are  vastly  important ;  and  that 
they  are  certainly  quite  as  important  to  the  insured  party,  as  to  the 
company  insuring.  For  our  present  purposes,  it  will  be  convenient  to 
consider  the  relations  of  Medical  Examiners  to  life  insurance,  and  the 
insurance  interests,  under  three  heads,  to-wit :  Their  relations  to  life 


VI 


companies  employing  them,  or  to  the  companies'  agents.  Secondly,  to 
applicants,  or  parties  seeking  insurance  ;  and  thirdly,  to  the  medical 
profession. 

First :  their  relations  to  companies,  or  agents  of  companies.  It  is 
scarcely  too  much  to  say  that  the  ultimate  safety  and  stability  of  every 
l.fe  insurance  company  rests  in  the  hands  of  those  who  decide  upon  the 
character  of  its  risks  :  for,  however  great  may  be  its  resources,  or  with 
however  much  of  financial  skill  and  sagacity  its  affairs  may  be  managed, 
or  however  many  or  perfect  may  be  its  "  tables  of  mortality,"  it  is  abso- 
lutely certain  to  come  to  a  disastrous  end,  unless  its  risks  are  selected 
with  care  and  discrimination.  And  so  many,  and  so  insidious  are  the 
diseases  whereof  the  end  is  only  too  certainly  fatal,  that  this  can  only 
be  done  by  the  skilled  and  experienced  Physician.  To  render  the  office 
of  Medical  Examiner  to  the  greatest  degree  useful,  three  things  seem 
to  the  writer  absolutely  essential :  (ist)  That  the  best  talent  be  secured. 
(2d)  That  perfect  harmony  be  maintained  between  the  Examiner  and  the 
company's  representative  or  agent.  (3d)  That  the  Examiner  be  ap- 
pointed from  the  central  office  :  that  he  be  recognized  as  an  officer  de 
facto  of  the  company,  independent,  and  therefore  self-reliant,  in  his 
sphere  ;  and  responsible  for  the  proper  management  of  the  interests 
committed  to  his  charge. 

(ist)  It  is  an  absolute  and  palpable  wrong  for  any  company  to  ap- 
point as  its  Examiners  men  deficient  in  knowledge;  in  high-toned  hon- 
esty, in  devotion  to  the  interests  of  their  profession,  or  men  who  are 
wanting  in  that  practical  wisdom  which  can  only  be  acquired  by  actual 
experience.  It  is  wrong,  in  that  it  must,  to  a  greater  or  less  extent, 
militate  against,  rather  than  contribute  to,  the  safety  of  the  company  ; 
it  is  wrong,  in  that  it  needlessly  places  in  jeopardy  the  interests  of  those 
who  are  entirely  unable  to  protect  themselves,  namely,  the  policyhold- 
ers,  or  those  who  are  dependent  upon  them  ;  and  lastly,  it  is  wrong,  in 
that  it  must  inevitably  bring  undeserved  odium  and  disgrace  upon  the 
medical  profession.  Notwithstanding  the  hordes  of  quacks  and  charl- 
atans which  infest  every  community,  competent  and  faithful  Medical 
Examiners  can  almost  everywhere  be  found ;  but  while  the  former  are 
forever  seeking  appointments,  the  latter  must  generally  be  sought ;  the 
former  are  only  too  apt  to  foist  their  services  upon  the  unwary  agent ; 


Vll 


the  latter  very  properly  regard  their  services  as  worth  seeking,  if  worth 
having.  Every  company  ought  to  be  held  to  a  stern  and  rigid  ac- 
countability for  the  character  and  ability  of  its  Examiners  ;  it  is  the  cus- 
todian of  vastly  important  interests,  which,  from  the  very  nature  of  the 
case,  cannot  be  looked  after  by  those  most  interested  in  its  integity. 
Its  policyholders  are  scattered  over  every  State  in  the  Union,  and  they, 
as  well  as  the  Examiners  upon  whose  recommendation  they  are  accepted, 
must  of  necessity  be  entire  strangers  to  the  Managers  and  Consulting 
Physician.  But  these  facts  furnish  not  the  least  excuse  for  appointing 
— or  at  all  events,  for  retaining  incompetent  Examiners  ;  rather  do  they 
render  it  more  imperatively  the  duty  of  those  selecting  them,  to  exercise 
the  greatest  care  in  obtaining  honest  and  skilled  physicians  to  fulfill 
this  most  important  trust ;  and,  so  perfect  and  complete  are  the  means 
for  acquiring  information  at  the  present  day,  that  no  company  can  plead 
ignorance  regarding  the  qualifications  of  its  Examiners,  and  at  the  same 
time,  maintain  a  creditable  reputation  for  shrewdness  and  good  man- 
agement. 

(2d.)  Unless  perfect  harmony  be  maintained  between  the  Exam- 
iner and  the  Agent  under  whom  he  is  acting,  the  company's  interests 
must  necessarily  suffer.  The  former  is  not  unfrequently  compelled  to 
reject  risks  upon  which  the  latter  has  expended  no  inconsiderable 
amount  of  time  and  labor,  and  which,  in  case  of  rejection,  must  go  for 
nothing.  Moreover,  applicants  are  often  rejected  for  reasons  which  are 
only  apparent  to  the  Examiner ;  and,  to  the  uneducated  ear,  or  un- 
skilled touch  of  the  Agent,  this  seems  an  unwarranted  stretch  of  power 
on  the  part  of  the  former.  With  the  Agent  it  is  a  question  of  commis- 
missions  ;  with  the  Examiner  it  is  a  question  of  safety  ;  and  these  two 
interests  sometimes  stand  diametrically  opposed  to  each  other.  But  it 
is  for  precisely  this  reason  that  the  Medical  Examiner  is  employed  at 
all ;  and,  unless  he  resolutely  stands,  like  an  alert  and  faithful  senti- 
nel, between  the  company  on  the  one  hand,  and  the  unsafe  and  unde- 
sirable applicant  seeking  admission  thereto  on  the  other,  he  signally 
fails  of  fulfilling  his  obligations  to  the  former,  and  renders  his  office  not 
only  useless,  but  positively  harmful.  This  course,  however,  although 
exceedingly  desirable  and  important  so  far  as  the  company  is  concerned, 
must  of  course  sometimes  array  him  in  direct  opposition  to  the  pecu- 


Vlll 


niary  interests  of  the  Agent.  But  with  this  the  Examiner  must  and 
can  have  nothing  to  do  ;  it  is  no  concern  of  his  whether  the  Agent  is 
remunerated  by  stated  commissions  or  a  regular  salary  :  he  has  only  to 
do  with  the  safety  or  unsafely  of  the  risk  ;  and,  while  he  must  disregard 
all  else  but  this,  he  must,  at  the  same  time,  maintain  harmonious  rela- 
tions with  the  Agent.  We  propose  to  indicate,  in  the  next  place,  how, 
in  our  judgment,  this  can  best  be  done. 

(3d.)  The  Medical  Examiner,  at  least  in  every  situation  involving  any 
considerable  number  of  examinations,  and  especially  in  the  large  cities 
and  populous  towns,  where  almost  every  applicant  is  more  than  likely 
to  be  an  absolute  stranger  to  both  Agent  and  Examiner,  should  be 
appointed  by  the  authorities  at  the  home  office,  after  they  shall  have 
satisfied  themselves  that  he  is  precisely  the  man  for  the  place,  and 
unless  they  are  well  convinced  of  this,  he  should  be  dismissed  and 
another  and  more  satisfactojy  appointment  should  be  made.  What- 
ever may  be  the  actual  merit  of  the  Examiner,  unless  he  is  fortunate 
enough  to  possess  the  entire  confidence  of  the  Managers — especially 
the  Consulting  Physician — at  the  central  office,  he  cannot  resign  too 
soon.  For,  unless  the  central  authorities  implicitly  confide  in  him,  it 
will  be  impossible  for  the  Local  Agent  to  respect  either  him  or  his 
decisions  in  regard  to  applicants — especially  if  they  happen,  as  they 
sometimes  must,  to  be  adverse  to  the  interests  of  the  Agent.  For  this 
reason  the  Examiner  should  stand  in  the  attitude  of  an  officer,  recog- 
nized as  such  by  the  company  ;  his  department  should  stand  by  itself, 
subject  only  to  the  control  of,  and  responsiole  only  to,  the  home  office. 
He  should  not  be  a  mere  "  tenant  at  will,"  subject  to  ejectment  at  the 
pleasure  or  caprice  of  the  Agent ;  for  such  an  equivocal  position  would 
be  derogatory,  not  to  the  man  only,  but  to  the  position  he  vainly  at- 
tempted to  fill.  The  general  adoption  of  this  course  on  the  part  of  the 
companies,  will  most  certainly  enable  them  to  secure  and  permanently 
retain  the  best  medical  talent,  and  also  insure  harmonious  action  be- 
tween the  Agent  and  Examiner — both  of  which  conditions  are  exceed- 
ingly important  and  desirable. 

Secondly  :  The  relations  of  Examiners  to  parties  seeking  assurance. 
The  Examiner  is  of  course  bound  to  consider  the  interests  of  the  com- 
pany by  whom  he  is  employed  and  paid,  as  paramount  to  all  others  ; 


IX 


else  would  he  absolutely  endanger,  rather  than  contribute  to  the  com- 
pany's sifety  and  stability.  But  while  this  is  undeniably  true,  it  is  ako 
true  that  the  applicant  has  claims  which  he  cannot  properly  disregard. 
Life  insurance  has  now  become  something  more  than  &metz  privilege  ; 
it  has  come  to  be  almost  a  sacred  and  "  inalienable  "  right  to  every 
person  who  is  eligible  thereto :  and  no  applicant  should  be  lightly  or 
needlessly  rejected.  Every  applicant  coming  before  the  Examiner  is 
entitled  to  a  fair  and  impartial  examination  ;  if  obscure  or  unusual 
symptoms  present  themselves,  he  is  fairly  entitled  to  a  second  examina- 
tion, or  even  more  than  that  if  necessary  to  a  proper  understanding  ot 
the  case.  Frequently  does  it  happen  that  some  apparently  grave 
symptoms  depends  upon  a  merely  temporary  cause  ;  for  example,  ap- 
plicants in  perfect  health  sometimes  present  themselves  with  an  unusu- 
ally rapid  pulse,  or  with  the  respiration  unaccountably  frequent,  or  with 
countenance  flushed  and  excited — and  all  this  may  be  the  consequence 
of  excitement  or  perhaps  fear  ;  for,  to  very  many  people,  a  Physician's 
office  is  as  terrible  as  the  dungeons  of  the  Inquisition  ;  and  the  very 
best  insurance  risks  are  those  which  are  least  familiar  with  the  sanctums 
of  Doctors,  and  therefore  most  likely  to  give  full  scope  to  their  imagina- 
tions. Individual  peculiarities  or  "  idiosyncracies  "  are  sometimes  met 
with,  which,  though  generally  indicative  of  some  grave  and  perhaps  in- 
curable disease,  are  quite  normal  as  regards  the  persons  presenting 
them  ;  these  exceptional  cases  demand  a  fair  hearing  at  the  hands  of 
the  Examiner ;  though  it  must  be  admitted,  as  a  general  rule,  that 
absolute  strangers,  presenting  symptoms  which  are  ordinarily  asso- 
ciated with  organic  disease  of  any  important  organ,  must  be  rejected, 
even  though  they  may  be  in  other  respects  desirable. 

In  making  examinations  preliminary  to  life  insurance  as  well  as  in 
all  other  investigations  of  this  character,  the  Physician  is  likely  to  be- 
come acquainted  with  matters  of  a  strictly  confidential  nature,  which 
if  divulged,  might  prove  seriously  detrimental  to  the  party.  The  same 
standard  of  high-toned  professional  honor  should  guide  the  Examiner 
in  his  relations  to  applicants  for  life  insurance,  as  he  feels  constan  ly 
bound  to  observe  in  his  relations  to  patients  under  his  care ;  no  excuse 
can  be  found  for  disregarding  this  matter  in  the  one  case,  that  will  not 
apply  with  equal  force  to  the  other,  except,  of  course,  that  the  Exam- 


iner  is  bound  to  disclore  to  the  Consulting  Physician  all  facts  essential 
to  a  correct  understanding  of  the  case.  Finally,  the  Examiner  should 
not  forget  that,  however  unimportant  it  may  be  to  him,  individually, 
whether  an  applicant  be  accepted  or  rejected,  it  may  be  and  often  is 
a  matter  of  vast  importance  to  the  latter.  Many  a  man  turns  to  life 
insurance  as  the  only  means  by  which  he  can  provide  for  the  necessi- 
ties of  those  he  expects  to  leave  behind  him,  when  he  shall  have 
passed  away  ;  many  an  unfortunate  man,  whose  life  may  have  been 
one  constant  struggle  with  adversity,  sees  in  a  policy  of  insurance  the 
only  means  by  which  he  can  protect  his  family  from  actual  want,  after 
he  has  ceased  to  live.  Such  cases  must  not  be  lightly  rejected  ;  they 
are  always  entitled  to  a  careful  and  candid  examination,  made  under 
circumstances  which  are  not  unfavorable  to  the  applicant ;  symptoms 
which  are  merely  the  result  of  trepidation  or  of  the  excitement  of  the 
occasion,  should  be  cleared  up,  and,  in  all  regards,  the  Examiner  should 
give  the  applicant  a  fair  and  impartial  hearing,  with  the  fixed  resolution 
of  rendering  a  decision  which  shall  be  just  to  both  parties;  and  while 
this  rule  applies  with  peculiar  force  to  the  class  of  cases  just  cited, 
every  applicant,  whether  high  or  low,  rich  or  poor,  fortunate  or  unfor- 
tunate, has  the  unquestionable  right  to  expect  precisely  the  same  kind 
of  treatment ;  and,  when  it  is  added  that  a  needless  rejection  is  a  per- 
manent and  irreparable  injury,  inasmuch  as  it  must  always  stand  as  a 
grave  objection — perhaps  an  insuperable  bar — to  the  acceptance  of  the 
rejected  party  by  other  companies,  it  will  be  seen  that  these  observa- 
tions are  based  upon  principles  which  cannot  be  lightly  disregarded, 
without  doing  violence  to  the  demands  of  justice  and  equity. 

Thirdly :  the  relations  of  the  examiner  to  the  Medical  Profession. 
Every  Medical  Examiner  is,  in  an  important  sense,  a  "representative 
man,"  to  the  company  employing  him,  as  well  as  to  parties  seek- 
ing insurance.  He  is  to  them  the  exponent  of  the  present  standard 
of  medical  excellence  ;  for,  it  cannot  reasonably  be  supposed  that  a 
powerful  corporation  would  deliberately  appoint,  or,  at  all  events, 
long  retain,  as  the  custodians  of  its  safety,  inferior  or  incompetent 
men,  when  the  best  talent  is  quite  as  easily  accessible,  and  involves 
no  greater  outlay  of  expense.  Let  no  Medical  Examiner  for  a 
moment  suppose  that  he  has  a  merely  personal  interest  in  acquitting 


XI 


.himself  creditably  and  honorably  ;  that  his  'individual  interests  are 
alone  to  suffer  if  he  fails  to  perform  his  duties  satisfactorily  ;  but  let  him 
always  remember  that  he  has  been  selected  on  acccount  of  his  pre- 
sumed ability  and  acquirements;  that  every  blunder  he  commits,  and 
every  unprofessional  or  undignified  act  he  allows  himself  to  perform  re- 
flects with  damaging  force  not  on  himself  only,  but  on  the  Profession 
as  a  whole.  It  is  just  as  imperatively  his  duty  to  maintain  a  high  stan- 
dard of  professional  honor  in  the  discharge  of  his  duties  as  Examiner 
for  an  insurance  company,  as  it  is  in  any  other  duty  connected  with  his 
vocation  ;  just  as  much  his  duty  to  examine  an  applicant  carefully,  as  to 
diagnosticate  a  case  he  proposes  to  treat  carefully ;  just  as  much  his 
duty  to  frown  upon  and  discountenance  quackery  and  charlatanism  in 
this  matter  as  in  any  other.  And  this  is  due  to  the  insurance  com- 
panies, no  less  than  to  the  medical  profession  ;  ever  since  its  origin,  the 
interests  of  life  insurance  have  been,  to  a  great  extent,  committed  to  the 
hands  of  Physicians,  and,  from  the  very  nature  of  the  case,  this  state  of 
things  must  continue ;  they  alone  are  capable  of  deciding  as  to  the 
safety  or  unsafety  of  risks,  and  they  alone  are  capable  of  making  the 
observations  necessary  to  a  correct  understanding  of  the  laws  of  mor- 
tality. But  in  still  another  and  no  less  important  direction  do  the  inves- 
tigations of  medical  men  subserve  the  interests  of  life  insurance,  namely, 
in  observing  the  laws  and  conditions  of  health,  and  disseminating  in- 
formation thereupon  among  the  people ;  in  arresting  the  progress  of 
contagious  diseases,  and  rendering  them  comparatively  harmless,  and 
in  enforcing  salutary  regulations  for  the  preservation  of  the  public 
health  in  cities  and  towns.  The  tendency  of  all  this  is  to  enhance  the 
value  of  human  life  ;  to  render  the  business  of  life  insurance  less  haz- 
ardous, and  therfore  to  bring  it  more  directly  within  reach  of  those 
most  likely  to  be  benefited  thereby ;  thus  making  it  not  only  theoret- 
ically, but  really,  a  boon  and  a  blessing  to  those  who  are  unable  to 
make  any  other  provision  for  the  prospective  necessities  of  their  fam- 
lies.  To  such  a  work  as  this,  the  medical  profession  ought  to  yield  an 
active  and  hearty  support,  not  only  in  the  persons  of  a  few  of  its  mem- 
bers, but  as  a  compact  and  united  whole.  To  this  end  let  Medical  Ex- 
aminers so  discharge  their  duties  as  to  increase  the  confidence  of  the 
companies  in  the  profession  ;  let  them  remember  that,  to  the  companies, 


Xll 


they  are  the  acknowledged  exponents  of  the  standard  of  professional 
acquirement,  honor  and  integrity,  and  let  them  remember  that  they 
have  their  part  to  perform  towards  making  life  insurance,  in  a  larger 
sense,  the  institution  of  the  people. 


NOTE  PREFATORY. 


Life  Insurance  is  rapidly  growing  in  public  favor,  and  it  is  not 

extravagant  to  say  that  the  time  is  coming  when  it  will  be  more  gen- 
eral even  than  Fire  Insurance.  All  men  have  lives  —  not  all  have 
houses,  stores,  or  barns.  The  system  of  endowments,  non-forfeiting 
policies,  etc.,  has  gone  far  toward  making  what  before  was  consid- 
ered extra-prudential  and  exceptional,  a  matter  of  ordinary  business 
caution  and  common  usage.  That  the  Insurance  Companies  and  the 
nolders  of  their  policies  should  have  the  highest  possible  advantage, 
:t  is  clearly  necessary  that  none  but  lives  selected  with  great  care 
should  be  assured.  Hence  the  MEDICAL  EXAMINER  becomes  their 
indispensable  agent.  To  aid  him  in  the  performance  of  his 
important  work,  is  the  object  of  this  little  Manual. 

It  is  not  its  intention  to  be  argumentative,  statistical,  or  rhetorical. 
Neither  originality  in  substance  nor  method  is  sought  after — but  only 
that  more  clearness,  definiteness,  and  certainty  may  be  achieved,  by 
attention  to  the  suggestions  herein  contained. 

A  prime  object  has  been  to  concentrate  to  the  smallest  possible 
bulk.  Hence,  conclusions  only  are  given  —  reasons  and  authorities 
are  rarely  alluded  to. 

Justice  to  myself  compels  me  to  add  that,  while  the  urgent  press- 
ure of  professional  duties  has  obliged  me  to  write  during  brief  and 
scanty  intervals  only — nevertheless,  the  ideas  advanced  are  the  re- 
sult of  matured  convictions,  strengthened  by  several  thousand 
personal  examinations  of  applicants  for  life  insurance. 

CHICAGO,  186^.  J.  A.  A 


THE  APPLICATION. 


The  Medical  Examiner  should  first  read  carefully, 
point  by  point,  the  interrogatories  proposed  by  the 
Company  for  which  he  is  acting,  and  the  answers  of  the 
applicant.  This  will  save  time,  and  indicate  those 
circumstances  which  require  especial  investigation. 
The  form  generally  adopted,  proposes  twenty -five 
questions  —  twenty-three  of  which  demand  the  scru- 
tiny of  the  Examiner.  For  the  purpose  of  brevity, 
we  adopt  the  order  of  the  form. 

I 

Name,  Residence  and  Occupation. —  The  name 
identifies.  The  residence  will  suggest  at  once  tne  na- 
ture of  the  causes  of  the  diseases  prevalent,  and  the 
relative  salubrity  of  the  locality.  The  moist  atmos- 
phere and  variable  temperature  prolific  of  phthisis  ; 
ochlesis,  the  products  of  animal  decomposition,  and 
foul  air,  fertile  in  typhoid  fevers  and  cachexiae ;  ma- 
larious districts  involving  endemic  diseases  which  may 
especially  prove  noxious  to  the  party,  etc.,  etc. 

THE  OCCUPATION — healthful  or  pernicious?  Sta- 
tistics show  the  relative  longevity  of  the  different  occu- 
pations of  men,  but  the  Examiner  should  superadd  to 


i6 

these  the  inquiry :  What  is  the  probable  effect  upon 
the  applicant  himself? — for  that  which  is  salutiferous 
to  one,  is  often  prejudicial  to  another.  Statistics 
establish  certain  general  propositions,  to  which,  it  must 
be  recollected,  many  exceptions  can  be  taken. 

PROFESSIONAL  MEN. — Teachers  exhibit  the  greatest 
longevity.  Next  come  Clergymen,  who  are  subject  to 
few  diseases  save  those  incident  to  sedentary  habits. 
Contrary  to  the  vulgar  opinion,  they  are  not  more 
liable  than  others  to  pulmonary  affections.  Dyspep- 
sia, with  its  incidents,  is  their  principal  affection. 
Lawyers  rank  next.  Then  professional  Lecturers, 
and  next,  Physicians.  Of  the  latter,  it  may  be  said, 
as  a  class,  they  have  not  the  ordinary  expectation  of 
life,  by  from  one-third  to  one-fifth  subtraction.  Nev- 
ertheless, the  variety  of  exposure  and  habits  is  such 
that  each  case  requires  isolated  investigation. 

ARTISTS. —  Painters  and  Sculptors  rank  among  the 
best  risks,  particularly  when  the  former  sketch  from 
nature,  and  the  latter  merely  model.  Portrait  paint- 
ers, and  sculptors  who  cut  marble  themselves,  are  not 
as  good  risks.  Photographers  and  Daguerreotypists 
rank  second  class. 

ARTISANS  AND  MECHANICS. —  Painters  using  lead 
and  oil  are  undesirable  risks,  yet  need  not  be  wholly 
rejected.  Workers  in  phosphorus  and  quicksilver 
stand  upon  the  same  level.  Stone  cutters  and  millers, 
and  similar  occupations,  where  insoluble  or  irritant 
particles  find  constant  access  to  the  pulmonary  surface, 
are  les-s  desirable,  but  improved  methods  of  ventila- 
tion, now  in  vogue,  render  them  less  objectionable  than 


17 

formerly.  Glass  blowers  are  poor  risks.  Compos- 
itors in  printing  offices  signally  demand  caution  in 
acceptance.  Blacksmiths,  Furnacemen,  Carpenters, 
Coopers,  and  Cabinet  Makers  range  among  the  most 
healthy  operatives.  Shoemakers  and  Harness  Makers, 
mainly  from  their  sedentary  habits,  are  second  class 
risks.  The  same  remark  may  be  made  of  Tailors. 
Butchers  and  Market  men,  aside  from  the  chances  of 
accident,  ( to  the  former  particularly, )  are  good  risks. 
Machinists,  Plumbers,  Tinsmiths,  Tallow  Chandlers 
and  Barbers,  and  similar  occupations,  are  generally 
good  risks.  Engravers,  Jewelers,  and  the  like,  are 
liable  to  the  diseases  of  sedentary  life,  but  are  other- 
wise unobjectionable.  Brewers,  Confectioners,  Dyers, 
Hatters,  Bakers,  and  others  whose  business  involves 
constant  exposure  to  warm  vapors,  often  impregnated 
with  medicinal  or  poisonous  substances,  are  not  as 
desirable.  Chemists,  Assayers,  Gilders,  Tobacconists, 
etc.,  are  liable  to  the  same  objection.  Day  Laborers, 
unless  exposed  f.o  accident,  are  equally  as  good  risks 
as  mechanics.  Agricultural  Laborers,  in  salubrious 
localities,  are  the  highest  order  of  desirable  applicants. 
The  best  lives,  other  things  being  equal,  are  those 
of  persons  engaged  in  out-door  and  yet  protected  em- 
ployments, where  the  occupation  is  somewhat  seden- 
tary, and  yet  combined  with  a  certain  amount  of  mus- 
cular exercise,  with  pure  air,  and  variation  enough  to 
secure  a  stimulating  impression  upon  the  system. 
Inertia,  indolence,  and  absolute  uniformity  of  me- 
teorological influences,  are  as  prejudicial  as  over- 
exertion  and  atmospheric  vicissitudes. 
2 


II. 

The  Age, —  Different  ages  predispose  to  particulai 
diseases.  So,  also,  hereditary  diseases,  according  to 
their  kind,  may  be  outgrown,  or  not  yet  arrived  at. 

During  the  period  of  increase,  extending  to  about 
the  twenty-fifth  year,  (varying,  of  course,  in  indi- 
viduals,) the  tendency  to  disease  and  death  is  propor- 
tionately very  great.  One-tenth  of  all  children  born 
die  the  first  month.  In  large  towns,  nearly  one-half 
die  before  the  fifth  year.  Respiratory  and  strumous 
diseases  are  especially  fatal  between  puberty  and  the 
age  of  maturity  —  placed  at  twenty-five.  None 
should  be  insured  before  puberty,  except  at  extra 
rates.  Between  that  period  and  maturity,  the  party 
demands  especial  investigation  of  the  respiratory  and 
glandular  systems.  Continued  fevers,  of  the  typnoid 
type,  are  also  liable  to  be  destructive  during  this  pe- 
riod. The  exanthems  readily  implant  the  germs  of 
phthisis  and  other  strumous  disorders. 

Rheumatism,  if  it  now  occurs,  in  consequence,  per- 
haps, of  the  excessive  activity  of  the  sanguineous 
system,  is  exceedingly  liable  to  beget  organic  disease 
of  the  cardiac  valves,  with  its  subsequent  results. 

From  the  twenty-fifth  year  to  the  thirty-fifth,  or 
fortieth,  or  age  of  maturity,  the  best  risks,  c<eteris 
paribus,  are  chosen.  During  this  period,  the  applicant 
stands  more,  so  to  speak,  on  his  own  individuality. 
Hereditary  predispositions  affect  him  less,  and  external 
agencies  are  easiest  resisted  when  tending  to  disease 
The  habits  and  external  influences  now  require  mor» 
careful  survey. 


'9 

From  the  fortieth  year,  at  latest,  decline  commences. 
Hereditary  diseases  regain  their  dangerous  tendency, 
and  acute  affections  are  met  with  less  power  of  resist- 
ance. Yet,  acute  diseases  of  various  forms  are  less  to 
be  dreaded  than  during  the  mobile  years  previous  to 
maturity.  The  progress  of  changes  in  the  system  is 
slower,  and  the  tendency  is  to  congestions  rather  than 
inflammations ;  to  urinary  diseases ;  to  fatty  degenera- 
tions ;  to  cardiac  and  other  obstructions  from  undue 
deposits ;  to  dropsies,  apoplexies,  paralyses,  and  the 
like. 

The  following  table  shows  the  expectations,  or 
average  duration  of  life  of  each  individual,  calculated 
from  the  Carlisle  table  of  mortality : 


AGE. 

EXPECT- 
ATION. 

AGE. 

EXPECT- 
ATION. 

AGE. 

EXPECT- 
ATION. 

AGE. 

EXPECT- 
ATION. 

0 

38.72 

18 

42.87 

35 

3I.OO 

52 

19.68 

I 

44.68 

"9 

42.17 

36 

30.32 

53 

I8.97 

2 

47-55 

20 

41.46 

37 

29.64 

54 

18.28 

3 

49.82 

21 

40.75 

38 

28.96 

55 

17.58 

4 

50.76 

22 

40.04 

39 

28.28 

56 

16.89 

5 

51.25 

23 

39-31 

40 

27.61 

57 

16.21 

6 

51.17 

24 

38.59 

41 

26.97 

58 

15.55 

7 

50'80 

25 

37.86 

42 

26.34 

59 

14.92 

8 

50.24 

26 

37-H 

43 

25.71 

60 

H-34 

9 

49-57 

27 

36.41 

44 

25.09 

61 

13.82 

10 

48.82 

28 

35.69 

45 

24.46 

62 

13.31 

ii 

48.04 

29 

35.00 

46 

23.82 

63 

12.81 

12 

47.27 

30 

34-34 

47 

23.17 

64 

12.30 

13 

46.51 

31 

3368 

48 

22.50 

65 

11.79 

«4 

45-75 

32 

33-°3 

49 

(2I.8l 

66 

11.27 

'5 

45.00 

33 

32.36 

50 

'21.11 

67 

10.75 

16 

44.27 

34 

31.68 

5i 

20.39 

68 

10.23 

17 

43-57 

Other  tables  vary  this  expectation  from  one  to  two  per  cent. 


20 

But  it  should  be  recollected  that,  in  individua. 
cases,  the  expectation  of  life  may  be  increased  by  pass- 
ing beyond  certain  ages  —  a  fact  wholly  ignored  by  the 
tables.  Thus,  for  example,  where  there  is  clearly  an 
hereditary  tendency  to  phthisis — when  parents,  or 
brothers  or  sisters  have  died  of  the  disease  before 
twenty-five  or  thirty,  and  the  party  has  lived,  and  is 
now  in  good  health,  at  the  age  of  forty,  half  the  danger 
may  be  said  to  have  passed ;  at  fifty,  three-fourths  or 
four-fifths ;  and  at  sixty,  but  a  mere  modicum  re- 
mains— certainly  not  over  one-fifteenth  or  twentieth,  if, 
indeed,  it  may  be  said  to  exist  beyond  that  of  other 
persons  without  hereditary  predisposition  of  any  sort. 

On  the  contrary,  the  tendency  to  gout,  urinary  dis- 
eases, insanity,  apoplexy,  paralysis,  etc.,  increases 
with  the  progress  of  declining  years. 

It  is  safe  to  say  that,  when  tables  indicate  a  pro- 
gressive diminution  of  the  life  expectation,  this  idea 
should  be  modified  and  corrected  by  a  full  understand- 
ing of  the  hereditary,  constitutional,  or  acquired 
tendency  to,  or  relief  from,  special  forms  of  disease. 

III. 

The  Marriage  Relation  suggests  hygienic  influences 
so  obvious  that  it  is  unnecessary  to  delay  in  its  con 
sideration.  Married  men  are  usually  the  most  desira- 
ble risks.  General  statistics  show  that  even  with 
females,  the  dangers  incident  to  maternity  do  not  ma- 
terially impair  the  risk.  A  woman  who  has  once 
borne  a  child  with  no  extraordinary  difficulty,  is  a 


21 

better  risk  than  the  primipara,  and  married  women  than 
those  who  are  unfortunately  single.  The  circum- 
stances of  previous  labors,  if  any  have  occurred, 
should  be  fully  understood,  and  reference  had,  if 
possible,  to  the  attending  physician. 

In  large  towns  and  cities,  applications  are  frequently 
made  by  those  neither  married  nor  single,  for  insurance. 
These  applications  are  not  infrequently  made  by 
"  housekeepers,"  who,  having  passed  the  heyday  of 
their  years  without  physical  impairment,  save  that 
which  years  may  bring,  become  solicitous  of  providing 
by  endowment  for  later  old  age,  or  else  for  the  support 
of  dependants.  These  cases  are  not  desirable,  neither 
is  it  necessary  utterly  to  refuse  them.  But  the  most 
rigid  investigation  is  requisite  before  they  are  recom- 
mended. 

IV.  &  V. 

Sobriety  and  Temperance  —  Use  of  Opium,  etc  — 

The  habitual  drinker  of  alcoholic  spirits,  or  the  ha 
bitual  opium-eater,  should,  as  a  rule,  be  rejected.  The 
inquiry  proposed  to  the  applicant  will  rarely  secure  a 
correct  answer.  Very  few  will  voluntarily  admit  either 
intemperance,  gluttony,  or  other  generally  recognized 
vice.  The  Medical  Examiner  is  expected  to  guard 
the  interests  of  the  Company  and  co-insurers,  by  ob- 
serving carefully  the  signs  of  excessive  stimulation, 
as,  unfortunately,  too  often  furnished  by  votaries  of 
Alcohol,  Opium,  Chloroform,  Ether,  Cannabis  Indica, 
and  the  like.  The  consumption  of  other  stimulants 
and  narcotics  besides  alcohol,  has  notably—- we  might 


22 

well  say  enormously  —  increased  within  several  years 
past.  The  alcoholic  breath  is  readily  detected,  but 
equally  clear  to  the  educated  perception  is  the  effect 
of  other  narcotics  and  stimulants.  Too  often  the 
applicant  is  induced  to  apply  for  assurance,  by  self- 
consciousness  of  his  indulgence  in  some  pernicious 
method  of  excitement,  which  he  knows  tends  to  short- 
en life,  but  which  he  vaguely  believes  he  can  abandon 
or  control  before  it  is  too  late. 

INTEMPERANCE,  by  which  we  mean  not  merely  drunk- 
enness, but  an  inordinate,  pernicious  habit  of  stimula- 
tion by  something,  is,  as  likely  as  rheumatism,  gout, 
insanity,  or  tuberculosis,  to  be  hereditary. 

The  family  history  here  becomes  noteworthy.  A 
tuberculous  tendency  may  be,  to  a  certain  extent,  con- 
trolled by  hygienic  influences  ;  among  which  may  be 
numbered  the  use  of  stimulants  of  various  kinds. 
The  rule  for  the  Medical  Examiner  is  this  :  If  the 
stimulant  taken  invigorates  digestion  and  assimilation, 
then  it  is  not  cause  for  rejection  :  if  it  merely  excites 
the  nervous  system,  it  is  an  objection  to  the  risk. 
Observe  —  invigoration  of  digestion  and  assimilation 
(real  power)  is  not  to  be  confounded  with  mere  in- 
crease of  adipose  tissue,  which  is  often  indicative  of 
depression  of  nutritive  energy. 

Is  the  party  an  occasional  or  an  habitual  tippler  ? 
There  are  some  men  who  indulge  in  only  an  infrequent 
debauch,  and  in  the  interim  are  strictly  temperate.  Such 
a  habit,  if  ascertained,  impairs  materially  the  risk. 

The  habitual  drunkard  is  well  described  by  Dr. 
Brinton  :  "  The  chief  characteristics  one  can  briefly 


express  in  words,  are  the  fiery,  unctuous  skin,  with  its 
secretions  reeking  with  volatile,  fatty  acids ;  the  red 
and  ferrety  eyes,  with  their  fitful  glare,  rather  than 
gleam  ;  the  furred  tongue ;  the  fetid  breath,  and  the 
trembling  limbs,  that  often  announce  the  impression 
made  by  the  copious  habitual  ingestion  of  alcohol  on 
the  stomach  and  nervous  system  respectively." 

Other  suggestive  appearances  are  afforded  by  sunk- 
en eyes  surrounded  by  dark  circles  ;  pallid,  or  even 
waxy  complexion ;  moist,  sticky  skin ;  emaciation ; 
tremulousness  of  the  muscles,  unless  rendered  tem- 
porarily tense  by  a  full  dose  of  the  stimulant ;  a  ner- 
vous restlessness  of  the  whole  person  ;  often  abstrac- 
tion of  mind,  etc.,  etc.  Many  times  the  party  will 
temporarily  conceal  the  habit,  or  even  persuade  him- 
self it  does  not  exist  to  an  injurious  extent;  hence  the 
necessity  for  great  caution.  The  friend's  certificate 
here  becomes  indispensable,  and  the  attending  physi- 
cian's testimony  should  not  be  overlooked. 

Habitual  opium-eating  does  not  show  such  easily 
described  and  unmistakable  marks,  yet  can  rarely  be 
concealed  from  an  observer  of  ordinary  sagacity,  whose 
attention  is  directed  to  the  point. 

Notwithstanding  the  singular  character  of  the  testi- 
mony in  the  Earl  of  Mar's  case,  in  England,  in  1832, 
it  is  safe  to  say  that  opium-eating  lessens  the  expecta- 
tion of  life,  and  is,  therefore,  a  valid  reason  for  de- 
clining the  risk.  Undue  nervous  irritability ;  a 
peculiar,  shuffling  gait ;  flabby  muscles  ;  drooping 
eyebrows,  with  dark  lower  lids,  while  the  eye  itself 
seems  to  sink  and  grow  dim  ;  with  general  marks  of 


old  age  ;  or  else,  while  the  stimulant  has  full  effect, 
excitement  with  brilliant  eyes,  but  contracted  pupils  ; 
quick,  restless  movements  ;  or,  sometimes,  in  differ- 
ent temperaments,  general  dullness,  lassitude,  sleepi- 
ness, and  a  relaxed  skin,  with  sticky  perspiration,  and 
husky  voice.  When  the  applicant  says  he  has  a  diar- 
rhcea  or  dysenteric  difficulty  which  requires  occasional, 
doses  of  opium,  when  the  eyes  are  hazy,  and  the 
tongue  has  a  whitish  coat  ;  when  there  is  a  mucous 
secretion  from  the  eyes,  with  frequent  hawking  of 
mucus  from  a  flabby  mucous  membrane  of  the 
pharynx,  and  perhaps  of  the  nose.  When  he  is  a 
married  man,  and  with  these  symptoms,  has  no  chil- 
dren, carefully  observe  and  reject  him.  Much  must 
be  left  to  professional  discretion  —  but  cave  canem. 


Vaccinated?  —  A  person  who  has  never  been  vacci- 
nated or  had  the  small  pox,  should  not  be  accepted. 
If  vaccinated,  the  inquiry  should  be  :  Was  the  vacci- 
nation successful  ?  and  then,  how  recently  was  the 
operation  performed  ?  A  successful  vaccination  many 
years  previous,  is  not  sufficient,  but  if  it  has  been  lie- 
quently  repeated  without  infection,  the  case  may  be 
deemed  clear.  In  doubtful  cases,  examine  the  cica- 
trix,  or  re-vaccinate  at  once.  If  small  pox  or  vario- 
loid  has  occurred,  it  requires  especial  caution  as  to  the 
condition  of  the  lungs  and  intestinal  mucous  mem- 
brane. The  date  when  it  occurred  should  be  given, 
and  the  fact  of  perfect  or  imperfect  recovery  noted. 


VII.  &  VIII. 

Residmice  in  a  Foreign  Climate, —  Without  ex- 
act reference  to  isothermal  lines,  natives  of  the  zone 
extending  from  the  thirtieth  to  the  fiftieth  parallels  of 
latitude,  may  be  considered  as  the  best  risks.  An  ac- 
quaintance with  the  meteorological  condition  of  par- 
ticular localities,  is  of  great  importance.  Excessive 
thermometrical,  barometrical  and  hygrometrical  varia- 
tions, in  any  particular  locality,  usually  impair  risks, 
by  rendering  them  subject  to  various  diseases. 

Thus,  moist,  warm  situations  usually  involve  the 
malarious  diseases ;  cold,  or  variable,  and  moist  re- 
gions are  prolific  of  tuberculous  cachexiae ;  dry  (yet 
variable  in  temperature)  districts,  render  rheumatic 
and  inflammatory  diseases  more  dangerous.  On  equal 
parallels-,  the  temperature  of  Europe  is  higher  than 
that  of  America,  and  excepting  the  influence  of  the 
changes  produced  by  cultivation,  present  the  diseases 
of  lower  climates  in  higher  latitudes.  General  tem- 
peraments are  varied  by  persistent  climatic  influences. 
(Fid.  p.  6 1,  et  seq.) 

ACCLIMATION  IN  THE  SOUTH.-— Whilst  men,  almost 
alone  of  animals,  can  range  from  the  Equator  to  the 
f<  open  Polar  Sea,"  with  apparent  impunity,  by  observ- 
ing certain  precautions  which  their  reason  and  knowl- 
edge suggest,  nevertheless,  they  subject  themselves, 
sooner  or  slower,  to  organic  changes  which  are  termed 
briefly  "acclimation."  These  changes  render  them  less 
iable  to  the  acute  diseases  of  localities,  or  endemics 


26 

but  they  are  fraught  with  much  significance  to  tne 
insurance  examiner. 

More  than  two  thousand  years  ago,  the  naturalist 
Pliny  noticed  that  "  those  who  are  seasoned  can  live 
amid,  pestilential  diseases."  The  reason  of  this  mav 
be  a  matter  of  speculation,  but  of  its  essential  truth 
there  can  be  no  doubt.  The  organic  changes  thus 
brought  about  express  themselves  in  the  larger  phase 
of  different  races  of  men,  begotten  through  the  opera- 
tion of  ages  of  similar  influences  acting  on  parent  and 
progeny. 

Without  descending  to  minutiae,  it  may  be  said  the 
Northerner  going  South  may  become,  to  a  certain  ex- 
tent, acclimated  by  physical  changes  in  the  skin,  liver 
and  spleen,  especially  involving  their  heightened  ac- 
tivity of  interstitial  change,  and,  usually,  increase  in 
bulk.  Increased  activity  of  any  organ,  according  to  a 
well  known  natural  law,  involves  greater  tendencv  to 
disease.  If,  instead  of  more  energetic  action  of  the 
skin,  there  is  less,  from  any  temporary  or  permanent 
cause,  then  the  mucous  membrane  of  the  intestine  will 
be  called  into  excessive  activity,  and  the  acute  or 
chronic  diarrhoea  of  tropical  climates  be  produced. 
Else  there  are  the  cc  bloated  belly,  distorted  features, 
dark  yellow  complexion,  livid  eyes  and  lips  ;  in  short, 
all  the  symptoms  of  dropsy,  jaundice  and  ague,  united 
in  one  person/' 

Coming  North,  the  comparatively  healthv  Soutnron 
tails  an  easy  victim  to  tuberculous,  nephritic,  and  in- 
flammatory diseases.  The  rule  is  to  observe  the  rela- 
tive activity  and  development  of  each  organ  ot 
apparatu0  involved  —  whatever  the  cause  of  variation. 


27 

Acclimation  to  the  so-called  malarious  fevers,  etc.,  of 
the  South,  gives  no  immunity  to  YELLOW  FEVER,  anv 
more  than  does  typhoid  fever  from  variola  at  tne 
North.  Yellow  fever  is  a  disease  of  cities  and  towns 
epidemic  usually,  and  requires  its  especial  prophylaxis 
—  not  gained  by  any  mere  acclimation.  As  Dr.  Not: 
emphatically  writes :  "  The  citizen  of  the  town  is 
fully  acclimated  to  its  atmosphere,  but  cannot  spend  a 
single  night  in  the  country  without  serious  risk  of 
life ;  nor  can  the  squalid,  liver-stricken  countryman 
come  into  the  city  during  the  prevalence  of  yellow 
fever,  without  danger  of  dying  with  black  vomit." 

The  immunity  from  second  attacks  of  yellow  fever 
is  nearly  complete,  yet  the  constitution  is  liable  to 
permanent  impairment  from  its  ravages,  and  in  all  cases 
organic  diseases  are  carefully  to  be  looked  for. 

The  immunity  from  diseases  prevalent  in  particula- 
localities  often  exhibited,  in  exceptional  cases,  is  due 
principally  to  two  causes  :  First,  The  peculiar  organi- 
zation of  the  individual  himself;  and,  Second,  The 
care  with  which  he  adapts  his  life,  manners  and  cus- 
toms to  his  changed  surroundings.  As  Dr.  Ham- 
mond remarks  :  "  For  an  Englishman  or  an  Ameri- 
can to  attempt  a  residence  in  latitude  80°  without 
changing  his  food,  clothing  or  habits,  by  making  them 
conform  to  the  climate  to  which  he  has  come,  would 
lead  to  but  one  termination  —  death.  But  if  he 
studies  the  conditions  by  which  he  is  surrounded,  and 
profits  by  the  experience  of  those  to  whom  it  is  nat- 
ural, he  becomes  habituated  to  the  new  order  of 
and  lives  in  health  and  comfort." 


28 

The  same  law  holds  good  with  reference  to  a  change 
to  hot  climates.  Hence,  he  who  has  shown,  by  actual 
experience,  that  he  has  maintained  good  health  in 
either  extreme  of  latitude,  may  be  more  safely  in- 
sured, cr,  if  already  insured,  be  granted  permission, 
more  readily,  to  take  up  a  Northern  or  Southern 
residence. 

Nearly  the  same  law  holds  good  with  regard  to  yel- 
low fever  or  other  epidemic  disease  —  the  best  pro- 
phylaxis is  for  the  individual  so  to  shape  his  habits  as 
to  keep  well — and  he  who  will  attempt  this,  is  the 
best  risk. 

IX.  &  X. 

Employed  in  the  Army  or  Navy? --The  careful 

examination  to  which  the  recruit  is  ordinarily  subjected 
before  being  mustered  into  the  service,  is  a  point  in 
his  favor,  if  he  was  received.  Questions  then  arise  as 
to  the  influence  of  the  service  upon  him.  The 
diseases  to  which  he  has  generally  been  exposed  are 
principally  "  typho- malarial  fever,"  rubeola,  camp 
diarrhoea,  dysentery,  rheumatism,  scorbutus,  pneu- 
monia, catarrh,  cardiac  changes,  Bright' s  disease,  and 
not  least,  venereal  affections. 

An  individual  who  has  escaped  permanent  systemic 
or  organic  disorder,  from  these  various  causes,  may 
generally  be  put  down  as  a  good  risk,  even  though  his 
personal  or  family  history  is  not  every  way  satisfac- 
tory. Nevertheless,  the  obscure  results ,  often  capable 
of  discovery  on  rigid  examination,  require  more  than 
usual  care,  before  accepting  the  applicant. 


29 

In  my  own  experience,  1  have  often  found  cardiac 
and  renal  diseases,  and  the  secondary  or  tertiary  forms 
of  syphilis  in  returned  soldiers,  discoverable  only 
after  most  careful  scrutiny.  The  exposures  and  ex- 
igencies of  the  service  involve  the  most  potent  causes 
of  organic  disease,  even  though  the  elasticity  of  many 
systems  prevents  immediate  manifestation  of  striking 
symptoms. 

PREVIOUS  EMPLOYMENTS,  AND  THEIR  EFFECT  ON 
HEALTH. —  The  present  occupation  may  be  ordinarily 
innoxious,  but  the  previous  employments  have  left 
lasting  traces  of  injurious  influence.  So,  again,  the 
present  business  may  be  such  as  to  endanger  the 
health  generated  by  previous  healthful  engagements. 
The  peculiarities  of  the  individual  here  require  cau- 
tious investigation.  (  Via.  Occupation. ) 

XI. 

Has  the  Party  had  any  of  the  following  Diseases? 


Fits, 

Fistula,      > 

Gout, 

Insanity, 

Liver  Complaint, 

Paralysis, 

Palpitation, 


Quinsy, 
Rheumatism 
Rupture, 
Scarlet  Fever, 
Spitting  of  Blood, 
Diseases  of  the  Urinaty 
Organs. 


Apoplexy, 

Asthma, 

Bronchitis, 

Consumption, 

Cholic, 

Diphtheria, 

Disease  of  the  Heart, 

Dropsy, 

Seriatim.  —  A  party  who  has  had  a  decided  attack 
of  APOPLEXY  should  be  rejected.  Evident  tendency 
Thereto  also  should  disqualify. 

ASTHMA  is  but  a  symptom  —  it  may  or  may  riot  be 
a  cause  of  absolute  rejection.  Each  case  requires 
specific  examination. 


30 

Observe — Asthma  may  occur  merely  from  local 
irritants  applied  to  the  respiratory  surface,  and  the 
causes  of  such  local  irritation  may  depend  upon  mere 
idiosyncrasy.  Or  it  may  depend  upon  blood  poison- 
ing of  various  kinds.  Thus  particles  of  hay,  soot, 
excessive  moisture,  atoms  of  certain  gases,  anima. 
emanations,  ipecacuanha  and  other  medicinal  substances 
are  capable  of  producing  more  or  less  severe  spas- 
modic asthma.  Such  cases,  irrespective  of  organic 
lesion,  do  not  necessarily  disqualify  from  insurance. 
Some  persons  always  have  asthma  in  certain  locali- 
ties— never  in  others.  Thus  C.  cannot  stay  a  single 
night  in  Ann  Arbor,  Mich.,  without  a  severe  par- 
oxysm of  asthma ;  yet  he  has  lived  years  in  Detroit, 
only  37  miles  distant,  without  a  single  attack.  A., 
well  known  to  me,  lives  in  California  with  perfect 
health  and  freedom  from  the  disease,  whereas,  in  the 
Northern  United  States,  he  is  a  constant  sufferer. 
These  individual  peculiarities,  and  the  suffering  they 
generate,  are  the  best  guarantee  that  the  party  will 
himself  protect  the  interests  of  the  Company.  Nearly 
the  same  remark  may  be  made  with  reference  to 
asthma  from  blood  poisoning — prominent  among  the 
causes  of  which  we  may  mention  malaria,  or  such 
other  causes  as  promote  portal  venous  congestion. 
Alcoholic  stimulants,  and  sometimes  even  unexpected 
articles,  as  sugar,  will  occasionally  produce  the  same 
result.  Here  the  persistence  of  the  cause  must  gov- 
ern the  judgment.  None  of  these  cases  wholly 
preclude  acceptance  of  the  risk. 

Again,  asthma  may  depend  upon  reflex  causes 
totally  independent  of  permanent  organic  disease.  It 


3' 

may  alternate  with  ague,  or  other  periodical  disorders 
It  may  depend  on  uterine,  vesical,  rectal,  or  even 
gastric  disorder.  It  may  be  dependent  solely  on  an 
excitable  temperament  and  emotional  influences.  The 
gravity  and  permanence  of  the  excito-motor  cause 
here  must  be  sought  out,  and  only  its  due  importance 
attached  But  Asthma,  which  is  the  symptom  of 
cardiac  obstruction — of  tuberculosis — of  emphysema — of 
acute  or  chronic  bronchitis  —  of  thoracic  tumors  —  or, 
perhaps,  aneurism  —  of  hepatic  venous  obstruction  from 
thoracic  disease,  or  parenchymatous  change  in  the 
liver  itself —  or  from  organic  cerebral  or  spinal  change^ 
should  utterly  preclude  insurance. 

BRONCHITIS. — A  proclivity  to  attacks  of  bronchitis 
should  disqualify,  not  only  from  the  dangers  of  un- 
complicated bronchitis,  but  because  it  is  so  often 
symptomatic  of  the  tuberculous  diathesis.  Again,  as 
indicative  of  nephritic,  cardiac,  gastric,  or  other  dis- 
eases of  remote  organs,  or  those  from  septic  causes, 
(typhoid,  syphilis,  etc.)  It  may  be  observed,  how- 
ever, that  bronchitis  may,  and  often  does,  leave  a 
condensation  of  a  portion  of  the  pulmonary  vesicular 
structure,  simulating  tubercular  deposit,  and  again, 
that  it  may  leave  behind  dilatations  of  the  tubes, 
which  simulate  very  closely  excavations  from  tuber- 
cular softening.  Resulting  emphysema  should  be 
carefully  searched  for,  and  its  fallacious  resonance  not 
confounded  with  healthy  lung-vesicular  structure. 
Popularly,  simple  pharyngitis,  and  all  slight  or  severe 
catarrhal  inflammations,  are  merged  in  the  general 
term  bronchitis ;  so  that  the  information  conveyed  bv 


the  patient's  own  statement  is  of  very  little  practical 
value. 

CONSUMPTION.  —  The  rule  is  absolute  that  consump- 
tive cases  should  be  rejected.  Physical  investigation 
is  always  to  be  exact,  for  the  healthiest  external  ap- 
pearance may  but  hide  the  germs  of  the  disease. 

CHOLIC. — This  term  indicates  but  a  symptom,  the 
significance  of  which  depends  solely  upon  its  cause. 
Taken  in  its  widest  sense,  we  may  say  that  at  the 
present  time,  improved  methods  of  diagnosis  and 
treatment,  have  robbed  the  disease  of  its  formerly 
dangerous  character,  and  unless  proceeding  from 
peculiar  causes,  it  need  not  be  considered  a  cause  for 
rejection.  The  well  known  forms  are  the  gastric, 
intestinal,  hepatic,  nephritic,  and  that  from  lead,  or, 
perhaps,  also,  copper  poisoning.  The  cholic  of  flat- 
ulency, or  temporary  dyspepsia,  does  not  particularly 
enhance  the  risk  —  neither  does  the  so-called  bilious 
cholic,  unless  the  patient  is  peculiarly  subject  to  it. 
If,  however,  the  latter  evidently  depends  upon  the 
passage  of  gall-stones,  and  frequently  recurs,  it  is  a 
cause  foi  rejection.  Where  painter's,  or  other  metallic 
cholic  has  occurred,  it  is  not,  alone,  to  be  considered 
cause  for  rejection,  unless  it  has  recurred,  and  partic- 
ularly, the  same  occupation  has  been  continued.  The 
lead  worker  who  has  had  this  cholic,  and  continues  in 
the  business,  should  be  rejected.  A  single  attack  of 
nephritic  cholic  need  not  reject  —  recurrence,  even  at 
a  distant  interval  of  time,  should  exclude.  Many  so 
called  cases  of  cholic  are  really  enteritis,  and  may  in- 
dicate marasmus.  The  local  and  general  evidences  of 


3J 

tuberculosis  of  the  mesenteric  glands,  must  be  inves- 
tigated. 

CARDIAC  DISEASE. —  Organic  disease  of  the  heart 
positively  excludes.  Physical  diagnosis  is  indispensa- 
bie  nere,  but  it  should  be  recollected  that,  as  a'  rule, 
while  the  healthy  heart  may,  from  accidental  causes, 
give  an  abnormal  sound  temporarily,  the  heart  dis- 
eased to  such  an  extent  as  to  reject,  can  not,  for  any 
continuous  period,  give  forth  healthy  sounds.  Ab- 
normality in  rhythm  or  impulse  may  depend  solely 
upon  temporary  causes,  and  so,  also,  may  abnormality 
of  sound  —  but  when  these  are  present,  the  parts 
should  always  be  re-examined.  Variations  in  rhythm 
or  impulse  may  be  individual  peculiarities,  and  there 
are  evidences  that  varied  sounds  may  also  depend  upon 
idiosyncrasy,  but  the  safer  rule  is  never  to  accept  the 
party,  unless  the  natural  sounds  may  be  heard.  When, 
from  any  cause,  cardiac  disease  has  frequently  occurred, 
and  abnormalities  are  present,  the  party  should  be 
turned  over  to  invalid  companies. 

DROPSY. —  This  is  another  symptom  which  may,  or 
may  not,  be  of  importance.  If  present  at  the  time 
of  examination,  no  chances  should  be  taken,  but  the 
party  advised  to  postpone  the  application.  It  may 
nave  been  a  sequence  of  malarious  disease  —  as  often 
from  ague  —  if  there  be  not  now  malarial  cachexia,  it 
is  no  cause  of  rejection  —  but  if  hepatic  or  splenic 
parenchymatous  disease  remain,  the  applicant  should 
be  rejected  or  postponed  until  that  is  cured.  It  may 
have  been  left  behind  by  scarlatina,  or  other  zymotic 
disease  —  if  it  has  not  recurred,  and  the  evidence  of" 
3 


34 

nephritic,  cardiac,  or  other  organic  disease  do  not  re- 
main, it  is  not  cause  for  rejection.  It  may  have 
resulted  from  peritonitis,  which  has  been  entirely  re- 
covered from  —  if  so,  the  party  may  be  received.  If 
from  chronic  peritonitis,  it  is  cause  for  rejection.  If 
it  occurs  from  renal  (Bright's)  disease,  from  perma- 
nent hepatic,  cardiac,  or  pulmonary  organic  affection, 
the  party  cannot  be  assured.  The  dropsy  from 
drunkard's  liver,  (cirrhosis}  vitiates  the  application. 

Aside  from  constitutional  causes,  the  effusion  into 
the  pericardium  is  more  grave  in  insurance  prognosis, 
than  that  into  the  pleural  cavity.  The  latter  than 
ascites,  and  ascites  than  that  into  the  areolar  tissue, 
osdema,  anasarca,  etc.  But  local  anasarca  always  ne- 
cessitates the  greatest  care,  lest  albuminuria  be  present 
or  impending,  or  lest  some  permanent  organic  disease 
is  its  origin.  Any  constitutional  cachexia,  as  syphilis; 
in  connection  with  the  dropsical  effusion,  even  though 
organic  disease  may  not  be  discovered,  precludes 
insurance. 

DIPHTHERIA,  aside  from  its  immediate  danger,  ma) 
lay  the  foundation  of  tuberculosis  —  may  be  followed 
by  albuminuria  or  dropsical  effusions,  or  more  or  less 
permanent  paralysis.  It  is  not  usually  mentioned  in 
the  list  of  diseases  about  which  the  party  is  ques- 
tioned, but  its  grave  sequelae  entitle  it  to  thorough 
consideration. 

FISTULA. —  Fistulas  are  of  importance,  as  indicative 
of  local  or  general  disease,  or  both.  Locally,  they 
may  indicate  the  presence  of  a  foreign  substance  at 
the  bottom,  as  more  particularly  a  bit  of  dead  bone, 


35 

or  cartilage.  In  each  of  these  instances  the  surgical 
pathology  becomes  the  prime  point  of  inquiry. 

The  cause  and  extent  of  the  necrosis  whether  of 
bone  or  cartilage.  The  location  of  the  bullet,  or 
splinter,  bit  of  cloth,  or  whatever  it  may  be.  The 
surgical  curability  of  the  salivary,  faecal,  urinary,  etc., 
false  outlet,  with  the  question  of  its  cause.  So  also 
of  the  mechanical  action  of  muscles.  The  import- 
ance of  the  organ  reached  by  the  fistulous  opening 
may  have  much  to  do  with  the  decision  of  the  case, 
e.  g.  bone,  gland.  Some  Life  Companies  vaguely  in- 
struct their  examiners  that  Fistulas  are  a  positive  cause 
of  rejection.  In  this  case  FISTULA  IN  ANO  is,  evi- 
dently, the  difficulty  intended.  But  whether  fistula  in 
ano  should  reject  depends  wholly  upon  its  cause  and 
extent. 

First  —  If  it  is  among  the  signs  of  tuberculosis,  it 
should  certainly  reject  —  whatever  opinion  may  be 
entertained  as  to  its  hastening  or  retarding  the 
tuberculous  development. 

Second — If  it  has  proved  obstinate  under  correct 
treatment,  it  should  disqualify. 

Third — If  it  is  large,  burrowing,  and  exhausting, 
it  is  ample  cause  for  rejection. 

But  if  it  is  traceable  to  ulceration  of  the  part  from 
merely  local  or  temporary  causes,  as  haemorrhoids, 
acute  dysentery,  or  direct  mechanical  injury  —  without 
evidences  of  the  tuberculous  diathesis,  or  remote  or- 
ganic disease — if  it  has  proved  amenable  to  appropri- 
ate treatment,  and  is  no  longer  a  cause  of  exhaustion, 
it  should  not  reject  the  risk.  Personally,  the  opinion 


36 

of  the  writer  is  that,  with  the  improved  surgica 
methods  of  the  present  time,  too  much  significance 
has  been  attached  to  this  usually  strictly  local  difficulty. 
FITS. —  Under  this  general  and  vague  designation, 
the  insurance  forms  prominently  intend  Epilepsy  in  its 
various  phases.  When  Epilepsy  is  clearly  present, 
whatever  its  degree  or  frequency  of  manifestation,  it 
utterly  disqualifies.  Not  that  it  necessarily  shortens 
life  per  se,  but  because  even  without  this  usual  result 
it  may  impair  the  mental  faculties,  or  dispose  to  acci- 
dents, which  essentially  impair  the  risk.  The  epilepti- 
form  convulsions  of  primary  dentition,  and  the 
changes  incident  to  that  epoch,  if  they  have  not  man- 
ifested a  disposition  to  return,  or  injured  the  mental 
faculties,  or  involved  paralyses,  in  later  life  do  not 
disqualify.  The  irregular  muscular  contractions  of 
simple  Hysteria,  unless  connected  with  organic  dis- 
ease, or  general  cachexia,  do  not  prevent  acceptance. 
Males  of  nervous  temperament  sometimes  manifest 
symptoms  very  like  those  of  Hysteria  with  its  queer 
symptoms — such  cases  should  be  carefully  investigated, 
but  these  symptoms  do  not  necessarily  disqualify. 
Youths  of  both  sexes  about  and  after  the  age  of 
puberty  for  several  years  may  exhibit  mild  or  severe 
epileptiform  symptoms,  or  even  decided  periodical 
convulsions,  yet  if  these  either  spontaneously,  01 
under  treatment  subside,  it  may  be  laid  down  as  a  rule 
that  if  after  several  years  they  do  not  recur,  the  risk 
is  a  good  one.  The  age  of  twenty-five  in  the  male 
and  twenty-three  in  the  female  may  l>e  considerc' 
critical  in  this  regard. 


37 

CHOREA,  in  all  particulars,  may  be  regarded  as 
identical  with  the  "fits"  of  the  formulary,  so  far 
as  its  pathology  and  influence  upon  longevity  is 
concerned. 

GOUT,  of  chronic  character,  and  particularly,  if  in 
any  degree  hereditary,  disqualifies.  But  it  does  not 
follow  that  all  sore  toes  are  gouty.  Analysis  of  in- 
dividual cases  is  indispensable.  The  habits  of  life, 
and  surroundings,  will  attract  the  attention  of  the 
examiner.  The  Dyspepsia  and  general  malaise 
discoverable  by  examination  are  of  more  significance 
to  the  cautious  medical  agent  of  the  Company. 

INSANITY  does  not  always  tend  to  shorten  life 
directly,  but  if  present  disqualifies  on  account,  first^ 
of  disease  of  central  nervous  organs  which  it  indi- 
cates :  and,  second^  because  of  the  greater  liability  to 
accidental  death  which  the  withdrawal  of  healthful 
reason  involves.  It  is  to  be  distinguished  from  the 
delirium  of  temporary  disease,  and  from  mere  eccen- 
tricity. Malarious  diseases  are  not  infrequently  fol- 
lowed by  an  interval  of  insanity,  sometimes  of  the 
most  active  character,  and  yet  which  recovered  from 
tends  not  an  hour  to  shorten  life.  Of  this  the 
writer's  personal  experience  has  given  him  abundant 
evidences.  Such  cases  need  not  necessarily  be 
rejected.  The  puerperal  state  often,  also,  involves 
this  condition  with  similar  prognosis  ;  but  if  puer- 
peral insanity  have  occurred,  it  is  better  not  to  insure 
unless  the  grand  climacteric  has  been  passed.  Hered- 
itary insanity,  and  a  single  attack  in  the  individual, 
or  marked  proclivity  thereto,  or  where  it  is  as  evident 


in  the  family  connection  as  other  hereditary  diseases 
adverted  to  should  reject.  The  well  balanced  mine1 
cannot  contemplate  suicide  without  horror,  but  the 
evidences  are  abundant  that  oftentimes  murder  and 
suicide  may  be  the  only  manifestations  of  the  hered- 
itary taint  of  insanity,  and,  therefore,  although  preg- 
nant signs  of  mania  in  any  of  its  forms  may  be 
absent,  and  general  good  health  apparent,  the  risk 
should  nevertheless,  in  such  cases,  be  declined.  Yet 
justice  to  applicants  requires,  when  insanity  is  men- 
tioned as  having  occurred  in  the  connection,  that  the 
particulars  of  the  case  be  inquired  into.  It  may  occur 
that  the  instance  was  one  from  some  incidental,  and 
not  hereditary  cause.  It  may  have  arisen  from  local 
injury,  from  septic  poisoning  of  the  blood,  or,  per- 
haps, have  been  merely  senile  mental  decay,  etc., 
in  either  instance,  not  invalidating  the  risk.  Other 
things  being  equal,  the  actual  presence  of  insanity  will 
lessen  the  chances  of  longevity  to  one-fifth  or  one-sixth 
the  healthy  standard. 

LIVER  COMPLAINT.  —  Hepatic  diseases  are  to  be 
looked  for  in  those  who  are,  or  have  been  residents  of 
malarious  districts  ;  in  spirit  drinkers  ;  and  those  of 
the  technical  bilious  temperament,  i.  Enlargement  of 
the  liver,  if  from  portal  venous  congestion,  may  not  in- 
validate the  risk  ;  if  from  hepatic  venous  congestion,,  it  is 
a  sign  of  disease  pregnant  with  danger,  and  while  pres- 
ent should  absolutely  reject.  The  hobnail  or  drunk- 
ards* liver  (cirrhosis)  should  reject.  As  an  isolated 
symptom,  the  contracted  or  small  liver  is  more  sus- 
picious than  the  enlarged  one.  Persistent  hepatic 


39 

disorder,  points  prominently  to  tuberculosis,  fatty 
degeneration,  cirrhosis,  or  malignant  diseases,  either 
of  which  will  disqualify.  Adjacent  tumors  may,  more 
or  less,  permanently,  obstruct  the  passage  of  bile,  or 
directly  interfere  with  the  action  of  the  organ.  Of 
course,  these  should  reject.  Abscesses  present  reject; 
but,  if  formerly  existent,  and  now  fully  recovered 
from,  are  to  be  judged  of  from  their  causes  and  effect 
upon  the  system.  The  abscess,  from  local  or  acci- 
dental cause,  has  less  significance  than  that  from 
pyaemia;  the  latter  than  that  from  abnormal  deposit,, 
as  of  tubercle,  cancer,  etc.  Recurring  abscesses  dis- 
qualify, whatever  the  cause.  A  tendency  to  the  forma- 
tion of  gall-stones,  with  ileus  or  jaundice,  if  recurrent,, 
should  be  an  obstacle  to  approval. 

JAUNDICE,  while  present,  postpones  acceptance.  If 
dependent  on  hepatic  venous  congestion,  it  rejects.  If 
it  depended  simply  on  portal  congestion,  as  occuring  in 
malarial  or  other  fevers,  it  is  comparatively  trivial. 
Observe,  it  is  only  a  symptom,  and  its  real  meaning 
necessitates  examination  and  judgment.  Thus  it  may 
appear  as  a  consequence  of  a  catarrhal  condition  of  the 
bile  ducts  ;  or  as  the  result  of  impaction  of  gall-stone, 
or  the  mechanical  pressure  of  tumors  ;  faecal  accumula- 
tions in  the  colon ;  from  lumbricoid  worms  in  the 
common  duct,  etc.  Or  it  may  be  an  evidence  of  ma- 
lignant degeneration,  or  of  permanent  organic  disease, 
as  tuberculous,  fibroid,  fatty  or  amyloid  degeneration, 
etc.  From  the  largely  more  frequent  causes  of  this 
symptom  being  temporary,  and  not  permanent  in  ope* 
ration,  the  isolated  symptom  'may  be  considered  as 


4o 

suggestive  of  investigation,  and  not  as  a  reason  by 
itself  for  rejection. 

PARALYSIS,  whether  simply  local,  paraplegic,  or 
hemiplegic,  demands  the  most  scrupulous  examination. 
Hemiplegia  or  paraplegia,  if  present,  totally  disqualify. 
But  if  formerly  present,  as  clearly  the  result  of  some 
merely  temporarily  acting  cause,  and  this  cause  has 
been  entirely  removed,  e.  g.  infantile  neurosis,  acci- 
dental lesion,  hysteria,  etc.,  it  may  be  passed  over. 
When  combined  with  cardiac  disease,  or  the  apoplectic 
diathesis,  even  though  there  be  apparent  health,  it 
should  reject.  The  import  of  the  local  cause  is  the 
important  point  of  inquiry.  Local  paralysis  may  oc- 
cur from  local  injury,  local  tumor,  or  similar  cause, 
and  not  disqualify.  When  present,  and  not  clearly 
explicable  as  the  result  of  a  removable  or  innoxious 
local  cause,  it  should  reject. 

PALPITATION  of  the  heart  is  a  symptom  of  little  sig- 
nificance. Always  noted  among  the  list  of  symptoms 
about  which  the  patient  is  questioned,  it  really  is  of 
no  importance,  save  as  directing  attention  toward  or- 
ganic disease  of  the  heart,  or  toward  dyspepsia  or  dis- 
orders of  innervation.  Taken  by  itself,  it  is  a  symptom 
which  attracts  attention  to  its  possible  cause,  but 
neither  accepts  nor  rejects. 

QUINSY,  or  Tonsillitis.  This  local  affection  is  prin- 
cipally important  as  one  of  the  evidences  of  the  tuber- 
culous diathesis.  It  is  capable,  it  is  true,  of  producing 
death  by  mechanical  occlusion  of  the  respiratory  pas- 
sages, but  this  is  so  rare  an  accident  that,  practically, 
it  may  be  neglected  in  calculating  the  chances  of  the 


risk.  The  same  remark  may  be  made  as  with  refer- 
ence to  the  danger  of  lancing  the  swollen  tonsils.  B\ 
this  little  operation,  branches  of  the  carotid  artery  may 
be  wounded,  and  death  result,  just  as  death  may  result 
from  choking  while  eating.  But  when  the  party  ad- 
mits being  subject  to  this  difficulty,  local  examination 
should  be  made  with  the  tongue  spatula,  or  better  still, 
the  laryngoscope. 

RHEUMATISM. — Frequent  and  aggravated  attacks 
of  rheumatism,  even  though  important  internal  organs 
may  not  have  been  previously  involved,  should  dis- 
qualify. Hereditary  rheumatism  impairs  the  risk. 
It  is  a  disease,  so  far  as  danger  is  concerned,  character- 
ized by  its  tendency  to  affect  particularly  the  white 
fibrous  tissues.  Thus,  the  cardiac  valves,  the  pericar- 
dium, the  dura  mater,  etc.,  become  liable  to  fatal 
change.  Uric  and  sulphuric  acids  are  largely  abundant 
in  the  secretions,  and  the  blood  becomes  abnormally 
fibrinous.  The  real  danger  of  this  diathesis  is,  in  the 
first  place,  from  acute  changes  which  may  involve 
speedy  dissolution,  or  from  deposits  which  necessitate 
grave  organic  disease  which  may,  later,  cause  sudden 
or  gradual  death.  It  is  capable  also  of  so  exhausting 
the  blood  itself,  as  to  render  the  risk  a  bad  one, 
irrespective  of  organic  change. 

In  judging  of  the  effects  of  the  organic  diathesis, 
the  atmospheric  vicissitudes,  and  the  habits  of  life  of 
the  party  must  be  noted  ;  next,  the  ordinary  condition 
of  the  skin  and  kidneys  ;  then,  most  assiduously,  the 
irritability,  or  actual  organic  cnange  of  the  heart 
structures  ;  then,  the  continuance  and  frequency  of 
-eturn  of  the  symptoms. 


42 

Most  patients  when  questioned  with  regard  to  the 
presence  of  rheumatism,  will  refer  to  occasional  pains 
in  the  muscles,  or  stiffness  in  the  joints,  of  a  quasi 
rheumatic  character,  as  being  true  rheumatism  ;  the 
Examiner  must  observe  that  these  are  not  intended 
by  the  question,  else,  no  person  could  be  considered 
as  exempt.  Acute  rheumatism,  or  a  decidedly  rheu- 
matic diathesis,  is  what  is  to  be  looked  after.  A 
single  attack  of  even  inflammatory  rheumatism  may 
not  disqualify,  although  it  may  have  been  severe.  But 
if  metastatic^  it  should  militate  against  the  risk.  If 
recurrent,  as  well  as  metastatic,  it  should  reject.  If  the 
case  has  been  progressive,  and  without  being  metastatic, 
has  passed  on  from  point  to  point,  and  ultimately 
involved  the  heart,  the  insurance  prognosis  is  more 
grave  than  in  case  of  mere  temporary  metastasis. 
Mere  thickening  of  fasciae  or  stiffening  of  the  joints 
from  long  previous,  but  not  recurrent  rheumatism, 
need  not  impair  the  risk  —  neither  lumbago,  nor  even, 
so-called,  sciatica  of  a  clearly  chronic  rheumatic  origin  ; 
but  when  local  paralyses,  or  temporary  or  permanent 
symptoms  of  apoplexy  have  resulted,  the  risk  should  be 
rejected.  Coagula  may  be  condensed  on  the  roughened 
cardiac  surfaces,  and  their  detachment  from  time  to 
time  determine  local  paralysis,  apoplexiae  or  even  mor- 
tification, to  the  extreme  astonishment  of  the  superfi 
cially  informed. 

Chronic  Catarrhal  Affections — sometimes  pdroxys- 
mal  in  character,  are  often  of  rheumatic  or  gouty 
origin,  so  also,  sclerotitis  and  even  meningitis  and 
maniacal  delirium.  The  quasi  rheumatism  of  mala- 
rious districts  requires  particular  examination,  and  so 


43 

also,  those  varieties  resulting  from  gonorrhoea  and 
syphilis  —  each  of  which  may  puzzle  the  practitioner, 
but  must  be  isolated  to  judge  of  its  influence  upon 
longevity. 

Metastatic  rheumatism  rejects;  syphilitic  rheuma- 
tism rejects  ;  especially  does  recurrent  rheumatism  of 
hereditary  character  reject;  chronic  sciatica  of  intense 
character  rejects  —  so  also,  does  severe  lumbago,  tic 
doloureux,  etc.  Whenever  rheumatism  is  acute  or 
chronic,  long  continued,  recurrent,  hereditary  or 
accompanied  with  cachexia,  the  insurance  company 
must  have  the  benefit  of  the  doubt  which  naturally 
arises,  and  the  party  be  declined. 

Rheumatism  is  liable  to  be  confounded  in  diagnosis 
with  erysipelas,  gout,  trichinous  disease  and  neuralgia  ; 
especially  is  it  liable  to  be  mistaken  for  phthisis, 
pleurisy,  etc.,  when  occurring  in  the  intercostal  mus- 
cles. Scorbutic  pains  are  very  liable  to  be  mistaken 
for  chronic  rheumatism.  In  prognosis,  not  more  than 
one  or  two  per  cent,  prove  fatal,  directly  or  remotely, 
and  half  of  these  of  the  latter  result.  At  the  present 
time,  from  improved  methods  of  treatment,  it  may  be 
confidently  asserted  that  the  disease  has  been  robbed  of 
half  of  its  individual  terror,  and  in  its  insurance, 
direct  or  remote,  prognosis,  of  three-quarters  of  its 
significance. 

RUPTURE. —  The  frequency  of  Hernia  in  its  differ- 
ent forms,  and  its  inherently  dangerous  nature,  renders 
this  point  one  never  to  be  overlooked.  According 
to  the  most  general  statistics,  hernia  is  to  be  found  in 
an  average  of  one  to  every  fifteen  of  the  a ^  alt  popula- 
tion. It  is  about  fourteen  times  more  frequent  in 


44 

males  than  females,  although  in  the  latter  it  is  more 
dangerous,  as  they  are  more  subject  to  the  crural  form, 
and  again,  because  from  motives  of  delicacy,  they  do 
not  as  early  apply  for  relief.  Hernia  progressively 
diminishes  in  frequency  from  birth  till  puberty,  and 
then  progressingly  increases  with  advancing  age.  Viz  : 
First  year —  i  in  21  ;  second  year —  i  in  29  ;  third 
year — i  in  37  ;  until  at  the  thirteenth  year  it  falls  to 
i  in  77.  Shortly  after  this,  its  frequency  rises  again ; 
thus,  at  the  twenty-first  year  there  is  i  case  in  32  ;  at 
the  twenty-eighth  year  —  i  in  21  ;  at  the  thirty-fifth 
year —  i  in  17  ;  at  the  fortieth  year —  i  in  9  ;  at  the 
fiftieth  year — i  in  6;  from  sixty  to  seventy  years  i 
in  4 ;  from  seventy  to  seventy-five  years — i  in  3. 
In  women  it  occurs  most  frequently  during  the  child 
bearing  years.  Umbilical  and  direct  hernia  are  less 
dangerous  than  the  inguinal  or  crural  forms ;  the 
latter  more  so  than  the  inguinal.  The  irreducible  is 
more  objectionable  than  the  reducible;  and  always, 
where  a  truss,  of  suitable  construction  fails  to  prevent 
descent  of  the  intestine,  the  risk  should  be  rejected. 
Cases  of  double  hernia  should  always  be  rejected. 
Observe  —  Occasionally  parties  suppose  they  have 
hernia,  when  there  is  simply  an  enlarged  gland,  or  a 
fatty  tumor,  retained  testis,  hydrocele,  etc.  Accuracy 
of  diagnosis  is  here  indispensable  to  protect  the  rights 
both  of  the  company  and  the  applicant.  Hernia, 
whether  single  or  double,  which  has  been  operated 
upon  and  apparently  cured,  it  should  be  remembered, 
is  liable  to  recur  on  gradual  absorption  of  the  new 
formation.  This  fact  will  have  weight  in  properly 
classifying  the  risk. 


45 

SCARLET  FEVER. —  The  larger  proportion  of  cases  - 
of  scarlatina  occur  before  the  insurable  age.  When 
it  occurs  in  the  adult,  its  secondary  results  demand 
most  cautious  examination.  These  not  rarely  involve 
breaking  down  of  the  constitution,  or  serious  local 
organic  changes,  which  imperil  the  risk,  and  this,  al- 
though the  primary  attack  may  have  been  apparently 
mild.  Taking  all  the  cases  together,  the  mortality 
from  scarlatina  is  scarcely  exceeded  by  that  of  any 
other  single  form  of  disease.  Consumption  and 
typhoid  fever,  (including  typhus,)  only  outrank  it  in 
fatality.  It  is  said  to  be  even  more  fatal  in  Europe 
than  in  this  country.  Fatal  as  it  is  in  the  onset,  the 
medical  examiner  has  more  to  do  with  its  subsequent 
ravages  upon  the  system ;  and  these,  it  is  found, 
principally  depend  on  primary  obstructions  to  the 
functional  action  of  the  kidneys.  Hence,  uraemia, 
dbuminuria,  anasarca,  dropsy,  etc.  Again,  its  local 
affection  of  the  eustachian  tube,  and  ear  may  ultimate 
in  destructive  caries  of  the  bones,  and  eventually 
prove  fatal  by  lesion  of  the  brain.  Thus  a  chronic 
ottorrhrea,  originating  from  this  cause,  militates  against 
the  risk,  although  it  may  not  aione  positively  reject. 
Of  course  albuminuria,  etc.,  reject.  If  the  party  has 
had  scarlet  fever  and  fully  recovered  from  it,  the  risk 
is  improved  thereby.  Many  of  the  Continental  Eu- 
ropeans reply  to  the  examiner  that  they  have  had 
scarlet  fever,  or  that  some  of  their  family  have  died 
of  it,  when  on  careful  questioning,  it  will  be  found 
that  "maculated  typhus"  is  the  disease  intended. 


46 

Again,  many  cases  of  slight  roseolar  eruption  are  con- 
founded with  it.  Such  cases  render  it  necessary  for 
interrogation  to  be  minute  and  exact  in  all  doubtful 
instances. 

SPITTING  OF  BLOOD. —  Unexplained  Hemoptysis  is 
one  of  the  most  pitilessly  exclusive  of  historical 
symptoms.  Primarily,  because  it  is  one  of  the  earliest 
precursors  of  phthisis,  and,  again,  because  it  tokens  its 
actual  existence.  So  large  is  the  proportion  of  those 
exhibiting  this  symptom  whose  lives,  sooner  or  later, 
terminate  by  consumption,  that  it  is  unnecessary  to 
argue  from  recorded  experience,  or  to  appeal  to  the 
abundant  statistics  which  have  accumulated.  Absence 
of  the  tubercular  taint  in  the  family  history,  or  of 
concurrent  signs  in  the  individual,  will  not  explain  it 
away.  Absence  of  physical  signs  is  scarcely  more  to 

oe  reafctrded.  under  such  circumstances,  than  those  of 

•^          * 

the  rational  sort.  The  proof  must  be  positive  that 
the  spitting  of  blood  came  from  other  cause  than  in- 
cipient or  present  tuberculosis  of  the  lungs.  Negative 
evidence*  u?  e  in  no  case  sufficient.  It  must  be  proved  that 
the  blood  came  from  the  gums,  the  nares,  the  pharynx, 
the  oesophagus  or  stomach.  Or  it  must  be  proved  that 
it  came  from  the  accidentally  abraded  larynx,  trachea 
or  bronchi ;  or  that  it  depended  solely  on  mechanical 
or  surgical  injury  of  the  vesicular  lung  structure  ;  or 
that  it  depended  solely  on  vicarious  causes.  Dr. 
Aitken  emphatically  observes  :  "  Cases  are  recorded 
of  its  so-called  idiopathic  occurrence,  as  from  variations 
(suddenly)  of  atmospheric  pressure,  ascending  high 
mountains,  or  descending  in  diving  bells,  violent 


47 

straining  efforts,  or  from  plethora  ;  but  in  such  cases, 
according  to  the  experience  of  Drs.  Fuller,  Walshe 
and  others,  c  there  is  usually  some  latent  mischief  in 
the  chest  —  some  local  cause  of  pulmonary  conges- 
tion—  some  mechanical  interference  with  the  capillary 
circulation  through  the  lungs.' '  Finally — we  observe 
that  it  may  depend  upon  disease  of  the  heart,  especially 
with  mitral  regurgitation;  upon  aneurism;  upon 
intra-thoracic  tumors,  either  malignant  or  non-malig- 
nant ;  or  upon  non-tubercular  abscesses.  But,  in  either 
case,  it  rejects  as  decidedly  as  though  dependent  on 
tuberculosis. 

HamatemesiS)  a  symptom  often  confounded  with 
haemoptysis,  is  of  vastly  less  significance,  nevertheless 
requires,  from  its  occasionally  dangerous  origin,  very 
careful  inquiry  as  to  its  real  cause.  The  blood  may 
have  come  from  the  nares,  the  throat  or  the  lungs,  have 
been  swallowed  and  vomited.  It  may  have  come  from 
aneurism  above  or  below  the  stomach,  from  ma- 
lignant or  non-malignant  gastric  ulcer ;  occasionally 
as  the  result  of  severe  gastritis ;  again  as  vicarious 
of  menstrual  or  other  discharges.  In  the  vast  majority 
of  cases  it  occurs  as  the  result  of  the  local  congestions 
of  malarious  diseases,  or  from  scorbutus  or  purpura. 
The  decomposed  blood,  or  coffee-grounds  vomit  of 
yellow  fever,  etc.,  need  hardly  be  alluded  to. 

DISEASES  OF  THE  URINARY  ORGANS. —  Under  this 
euphemistic  designation  are  intended — nephritis,  neph- 
ralgia,  cystitis,  stone  in  the  bladder,  diabetes,  haema- 
turia,  albuminuria  or  Bright's  disease,  prostatitis, 
spermatorrhoea,  gonorrhoea,  stricture,  urinary  fistula, 
syphilis,  or  other  organic  or  constitutional  diseases 


#8 

involving  the  urinary  organs,  primarily  or  secondarily. 
The  question  is  last  but  not  least.  The  obscurities 
of  diagnosis  and  prognosis  are  more  frequently  hidden 
here  than  in  any  other  part  of  the  animal  frame  work, 
and  coincidently,  here,  the  acuteness  of  the  medical  ex- 
aminer will  be  taxed  even  more  than  in  the  minutely 
studied  and  carefully  described  changes  of  the  thoracic 
'iscera.  For  the  physical  signs  are  clear  to  the  mode- 
rately educated  perceptive  faculties,  whilst  both  physi- 
cal and  rational  signs  exhaust  the  skill  of  diagnosis 
when  the  renal  and  subsidiary  organs  come  under 
view.  Chronic  nephritis  rejects,  and  so  also,  chronic 
nephralgia,  whatever  their  causes.  Cystitis,  if  present, 
rejects,  whether  acute  or  chronic.  Calculus  rejects  ; 
but  the  previous  passage  of  a  small  concretion  may 
not  disqualify,  unless  the  diathesis  be  strongly  marked, 
and  the  evidences  be  strengthened  by  hereditary  pre- 
disposition. Diabetes  necessarily  rejects,  but  doubtful 
cases  should  be  analyzed,  Albuminuria,  or  Bright' s 
disease  in  any  of  its  forms,  absolutely  rejects. 
Observe — that  organic  disease  of  the  kidneys  may  be 
present  without  albuminuria,  and  albuminuria  may 
occur  without  renal  organic  change,  but  either,  if 
present,  reject.  Prostatitis,  or  the  prostatic  enlarge- 
ment of  old  age,  if  sufficient  to  materially  interfere 
with  the  extrusion  of  urine,  must  reject.  Spermator- 
rhoea, so-called,  is  usually  merdy  a  catarrh  of  the 
urinary  mucous  membrane,  analogous  to  the  leuchor- 
rhcea  of  females,  and  of  trivial  importance.  It  is 
usually  an  evidence  either  of  mere  dyspeptic  derange- 
ment, or  of  improper  medication.  Notwithstanding 
the  stress  laid  upon  it  by  many  authorities,  it  is  safe 


49 

to  say  that,  in  at  least  nineteen  cases  out  of  twenty,  it 
in  no  wise  invalidates  the  risk.  True  spermatorrhoea 
will  manifest  itself  in  connection  with  other  symptoms 
involving  the  constitution  as  a  whole,  which  will  re- 
quire no  reference  to  this  as  necessary  to  sustain  an 
opinion.  Taken  as  a  symptom,  isolated,  it  is  of  as 
little  importance  as  a  nasal  catarrh.  The  previous 
occurence  of  Gonorrhcea  is  mainly  of  importance 
because  its  old  time  treatment,  by  balsamic  arid  other 
highly  irritant  remedies,  may  have  laid  the  foundation  of 
Bright's  disease  ;  or  because  it  may  have  been  followed 
by  septic  poisoning  of  the  blood,  involving  gonorrhceal 
rheumatism,  etc.  This  latter  is  capable  of  producing 
organic  diseases,  of  equal  importance  with  those  of 
rheumatism  from  the  usually  more  noted  causes. 
Stricture,  whether  the  result  of  gonorrhoea  or  acciden- 
tal causes,  requires  attention.  Is  it  spasmodic  or  per- 
manent ?  Is  it  permeable  or  impermeable  ?  Is  it  the 
result  of  merely  a  local  or  of  a  remote  cause  ?  It  is 
often  times  symptomatic  of  renal  or  vesical  organic 
disease,  and  these  disqualify.  If  trivial,  although 
troublesome,  it  is  of  less  importance.  If  it  require 
Syme's,  or  other  severe  operation  for  its  relief,  the 
insurance  should  be  postponed.  A  similar  remark 
may  be  made  of  urinary  fistula.  Let  it  be  cured, 
whatever  its  cause,  before  insurance.  All  malignant 
diseases  of  the  organs  of  course  reject.  In  all  cases 
of  renal  or  urinary  disease,  ONCE  MORE,  examine  the 
heart. 

SYPHILIS. — In  all  cases  where  secondary  or  tertiary 
syphilis  is  clearly  present  the  risk  should  be  postponed. 
This  disease  is  usually  capable  of  perfect  cure.  In 


s° 

badly  managed  or  cachectic  cases  it  becomes  dangerous 
to  longevity.  At  the  present  time  it  is  better  man- 
aged, and  the  chances  of  perfect  recovery  are  better 
than  heretofore.  But  the  rule  is  imperative — when 
present,  reject.  Observe,  historically,  the  distinction 
between  the  merely  local  sore,  (however  extensive  its 
ravages)  the  chancroid,  and  the  true  infecting  chancre — 
the  latter  only  of  insurance  import.  The  best  dis- 
posed party  applying  for  insurance  will  perhaps  deny 
its  previous  occurrence,  and  there  may  be  no  signs 
superficially  to  be  observed.  And  yet  it  is  easy 
for  the  moderately  instructed  examiner,  in  the 
majority  of  instances,  to  satisfy  himself  of  the  facts. 
Nevertheless,  the  present  writer  admits  the  loss  of  one 
risk  for  which  he  was  examiner,  by  giving  credit  to  the 
party's  own  statement  and  innocent  countenance. 
Many  cases  of  reported  consumption,  for  whose  de- 
mise the  examiner  is  held  professionally  responsible, 
are  in  fact,  syphilitic  decline  and  ultimate  decay.  But 
the  examiner  must  guard  himself  against  such  disas- 
trous result  by  stern  disregard  of  appearances.  This 
he  can  do  without  violating  any  of  the  proprieties. 
Observe  whether  there  are  any  traces  of  cutaneous 
eruption — whether  there  is  or  has  been  alopecia — 
whether  there  is  emaciation,  or  other  signs  of  depraved 
nutrition,  onychia,  enlarged  post-cervical  glands,  iritis, 
catarrh, white  patches  or  tubercles,  or  cicatrices  about 
the  mucous  membrane  of  the  mouth,  tongue  or  throat ; 
whether  there  are  nodes,  or  have  been  pains  in  the 
bones.  If  possible,  (perhaps  under  excuse  of  exam- 
ining for  hernia),  examine  for  the  significant  indu- 
ration of  the  inguinal  glands.  Indeed  when  the 

O  D 


51 

attention  is  directed  to  the  matter,  it  does  not  require 
much  tact  or  sagacity  to  make  up  one's  mind  safely. 
Fortunately  doubtful  cases  are  overrated  in  importance. 
It  is  perhaps  necessary  to  call  the  attention  of  the 
examiner  to  the  general  physiognomy  of  urino-genital 
diseases,  which  is  almost  too  unmistakable  for  the  ex- 
pert ever  to  be  deceived  in — but  for  the  inexperienced 
it  is  proper  to  say  that  it  is  both  capable  of  observa- 
tion and  indescribable. 

XII. 

HAS  THE  PARTY  HAD  INFLAMMATORY  RHEUMATISM? 

The  repetition  of  this  question  by  several  compa- 
nies in  their  forms,  attests  the  great  importance 
attached  to  its  satisfactory  answer.  But  sufficient  has 
been  written  upon  this  point  upon  p.  29.  et  seq. 

XIII.  &  XIV. 

SUBJECT  TO  DYSPEPSIA,  DYSENTERY  OR  DIARRHOEA? 

A  perfect  state  of  health  of  the  alimentary  canal 
and  its  subsidiary  organs  is,  of  course,  necessary  in 
order  that  there  should  be  perfect  nutrition  of  all 
parts  of  the  body.  Temporary  disturbances  may 
arise  from  temporarily  acting  causes  and  yet  not  inval- 
idate the  risk  ;  but  frequently  recurring,  or  persistent 
disorder,  whatever  the  cause,  throws  doubt  upon  it, 
and  then  the  case  must  be  carefully  diagnosed. 

Dyspepsia  is  primarily  noteworthy  because  it  is  one 
of  the  initiatory  symptoms  of  the  tubercular  diathesis. 


Or  it  may  evidence  organic  malignant  or  non-malig- 
nant disease  of  the  stomach.  It  may  be  sympathetic 
of  cerebral  or  renal,  of  uterine  or  spinal  affection  of 
more  or  less  serious  character.  In  the  larger  propor- 
tion of  instances  it  indicates  merely  a  catarrhal  condi- 
tion of  the  gastric  mucous  membrane,  or  slight  dis- 
turbance of  the  hepatic  functions.  But  whatever  its 
cause,  duration  or  severity,  whenever  present,  it  should 
receive  ample  consideration. 

Dysentery^  when  present,  rejects,  and  if  the  party  is 
subject  to  its  recurrence,  enquiry  must  be  made  as 
to  its  cause  and  origin.  Chronic  colitis  or  entero- 
colitis  reject.  But  many  cases  of  supposed  dysentery 
depend  solely  on  haemorrhoids,  local,  curable  ulcera- 
tion,  or  morbid  growths  about  the  rectum.  Neverthe- 
less it  is  safe  to  say  that  tenesmus,  discharges  of  blood 
and  pus,  especially  with  occasional  febrile  heat  and 
emaciation,  should  reject.  The  condition  of  the  liver 
in  such  cases,  should  be  carefully  observed. 

Diarrhoea  is  a  term  relative  to  the  habits  of  the 
individual.  It  does  not  refer  so  much  to  the  frequen- 
cy as  to  the  character  of  the  discharges.  Occasional 
attacks  of  acute  diarrhoea  may  occur  in  the  very  best 
risks.  Such  cases  point  to  an  examination  into  the 
habits  of  the  party,  whether  of  eating,  drinking  or  ex- 
posure to  vicissitudes  of  temperature,  moisture  or 
exercise.  Ill  regulated  diet,  imperfect  mastication, 
improper  quality  of  food,  irregular  hours,  and  intem- 
perance of  drink,  are  among  the  most  frequent 
causes, —  but  some  form  of  enteritis,  hepatic  derange- 
ment, or  disease  of  the  glandular  organs,  subsidiary  to 


53 

the  digestive  apparatus, —  Bright's  disease, — ochlesis, 
malaria,  with  other  agencies  are  capable  of  produc 
ing  the  same  result.  The  votary  of  opium  or  alcoholic 
stimulants  is  scarcely  ever  free  from  this  symptom. 
In  returned  soldiers,  or  those  addicted  to  vegetarian 
theories,  it  is  frequently  the  result  of  scorbutus.  When 
there  is  emaciation,  a  despondent  countenance,  dark 
circles  around  sunken  eyes,  a  sallow,  leaden  or  sodden 
skin,  a  sunken  abdomen,  a  red  and  pointed,  or  a  loose, 
pale  and  flabby  tongue, —  an  undue  indifference,  or  an 
augmented  irritability  of  the  nervous  system,  look  out 
for  diarrhea  and  its  cause. 

xv. 

HABITUAL  COUGH  ?  The  significance  of  an  habit- 
ual cough  in  life  insurance  examinations  depends 
wholly  on  its  cause ;  but  if  admitted,  it  requires  criti- 
cal examination.  It  may  depend  on  local  causes  in  the 
pharynx,  larynx,  trachea,  bronchia,  or  pulmonary  pa- 
renchyma. It  may  arise  from  cardiac,  hepatic,  gastric, 
intestinal  or  spinal  disease.  It  may  be  a  mere  morbid 
habit  of  the  nerves  and  muscles  involved  in  the  act. 
Primarily,  it  demands  physical  diagnosis  of  the  condi- 
tion of  the  lung  tissue,  especially  at  the  apices  of  the 
lobes, — together  with  a  rational  account  of  the  history 
and  diathesis.  Taken  as  a  mere  symptom,  Dr. 
Hartshorne's  statement  is  as  brief  and  satisfactory  as 
any  which  c^n  be  given,  viz : 

Cough  is  dry  and  hollow,  or  hacking,  when  nervous  or 
sympathetic. 

Dry  and  tight  in  early  bronchitis  ; 

Soft,  deep  and  loose,  in  advanced  bronchitis ; 

Hacking,  in  incipient  phthisis  pulmonalis  ; 


54 

Deep  and  distressing  in  confirmed  consumption  ; 
Short  and  sharp  in  pneumonia  ; 
Barking  and  hoarse  in  early  or  spasmodic  croup ; 
Whistling  in  advanced  membranous  croup  ; 
Paroxysmal  and  whooping  in  pertussis  [and  asthma.] 

It  is  needless  to  advert  to  the  character  of  the 
expectoration^  as  that  will  at  once  command  the  atten- 
tion of  the  practitioner.  It  may  be  mucous ,  purulent ', 
rusty,  bloody  and  muco-purulent,  nummular  and  heavy, 
putrid,  etc.)  etc.,  each  case  giving  its  distinctive  infor- 
mation of  value  to  the  examiner. 

XVI. 

MECHANICAL  OR  SURGICAL  INJURY  ?  Any  wound, 
however  trivial,  makes  its  own  demand  on  the  powers 
of  life.  The  amputation  of  an  arm  or  limb,  suggests 
inquiry  as  to  the  reason  for  the  operation.  Tuber- 
culous deposit,  malignant  disease,  caries  and  necrosis, 
requiring  surgical  interference,  clearly  invalidate  the 
risk  ;  whereas  mere  mechanical  injuries,  as  causes,  may 
not  materially  impair  it.  Caries,  or  even  necrosis, 
from  acute  periostitis  or  external  injury,  even  though 
ultimately  requiring  exsection  or  amputation,  are,  by 
no  means,  as  serious  objections  to  the  risk  as  exostosis, 
enchondroma,  osteo-sarcoma,  cachectic  deposit  and  the 
like.  Statistics  are  wanting  upon  this  point,  but  the 
writer's  general  judgment,  from  reading  and  observa- 
tion, is,  that  the  so-called  capital  operations,  although 
recovered  from,  apparently,  to  a  certain  extent  impair 
the  desirability  of  the  risk.  Individual  cases,  it  is 
true,  may  lend  color  to  a  different  opinion,  yet  the 
stern  proposition  remains,  that  great  injuries  to  the 


55 

system,  whether  accidental  or  surgical,  tend  largely  to 
exhaust  the  original  powers  of"  life  and,  fro  tanto,  im- 
pair the  insurance  expectation.  In  the  case  where  a 
limb  has  been  amputated  after  a  long  continued  dis- 
charge, which  has  become  habitual,  although  exhaust- 
ing to  the  system,  this  remark  is  especially  of  impor- 
tance. Apoplexies,  paralyses  and  various  organic 
affections  are  not  unlikely  to  supervene.  The  old 
ulcer  cc  cured,"  may  involve  new  and  unexpected  dis- 
ease Any  serious  mechanical  or  surgical  injury,  un- 
explained—  with  no  positive  evidences  to  the  contrary 
lessens  the  desirability  of  the  risk.  Long  continued 
confinement  in  the  recumbent  position,  of  itself,  pre- 
disposes to  disease ;  and  indeed  any  injury,  which, 
although  not  severe  in  itself,  has  necessitated  sedenta- 
ry habits,  with  deficient  air,  exercise,  etc.,  will  leave 
traces  of  its  deleterious  influence  on  special  organs  or 
the  general  system. 


A.VII. 

SEVERE  PERSONAL  INJURY  OR  DISEASE  WITHIN  THE 
LAST  SEVEN  YEARS  ?  This  query  is  based  on  the 
general  idea  that  if  more  than  seven  years  have  elapsed 
the  results  of  previous  disease  are  little  liable  to  be 
developed  The  popular  opinion  founded,'  as  usual, 
upon  an  antique  professional  idea,  is  that  the  whole  body 
is  changed  in  its  constitution  every  seven  years.  The 
instructed  examiner  needs  not  to  be  informed  that  all 
the  moving  and  acting  parts  are  changed  in  constitution 
within  a  space  of  time  scarcely  exceeding,  if  reaching, 
the  third  of  a  year.  The  practical  rule,  however,  re- 
mains, recent  diseases  require  more  careful  scrutiny 


56 

as  to  their  results  than  those  which  occurred  long  pre- 
vious. Some  companies  under  this  head  require 
details  as  to  the  character  of  the  disease,  and  a  reference 
to  the  attending  physician.  The  latter  point  will  be 
alluded  to  further  along  in  this  essay.  The  former 
will  suggest,  at  once,  to  the  intelligent  examiner,  the 
vast  differences  of  degree  and  danger,  of  immediate  or  re- 
mote disastrous  consequences,  which  may  obtain  in  dis- 
eases which,  for  nosological  purposes,  receive  the  same 
name.  Whatever  the  name,  the  practical  fact  remains 
that  no  disease  is  the  product  of  a  single  cause,  and  vary- 
ing with  the  multiplicity  of  influences  acting  upon  dif- 
ferent persons — will  be  the  result,  immediate  or  remote, 
of  any  single  cause  which  may  give  the  present  affection 
its  scientific  appellation.  Some  organizations  sustain 
and  oppose  the  specific  causes  of  certain  diseases  with 
little  derangement  even  of  functional  action  —  others 
manifest  the  evidences  —  the  gravest  evidences,  of 
organic  and  perhaps  ultimately  fatal  change. 

XVIII. 

LONGEVITY  OF  ANCESTORS  ?  In  the  United  States, 
such  is  the  character  of  the  population,  this  question 
can,  in  the  majority  of  instances,  be  answered  onlj 
with  reference  to  the  grandparents.  Yet  the  traditions 
of  families,  in  the  absence  of  registration  statistics  are 
worth  something.  The  descendants  of  certain  families 
are  notably  long-lived,  and  of  others  short-lived.  Co- 
incident with  this  fact  will  be  found  certain  hereditary 
tendencies  to  disease.  The  family  record,  if  tolerably 
complete  and  reliable,  is  of  the  highest  insurance  im- 
portance. It  is  well  known  that  hereditary  diseases 


not  infrequently  pass  over  one  generation  to  appear 
in  the  next,  or  subsequent  generations.  The  shape, 
capacity,  and  mode  of  action  of  internal  organs  are 
determined  by  the  parentage,  with  as  much  constancy 
as  the  external  likeness.  These  likenesses  determine 
particular  proclivities  to  intimate  textural  change,  with 
the  results  of  such  change.  Nations  and  tribes,  clans 
and  families  have  their  marked  peculiarities  of  external 
likeness,  with  almost  identical  tendencies  toward  death. 
This  is  especially  true  in  the  older  countries,  where 
rank,  caste,  and  custom  keep  up  the  usage  of  inter- 
marriage. It  is  of  perhaps  less  importance  in  the 
United  States,  where  these  distinctions  are  only  tem- 
porarily recognized.  Nevertheless  the  observation 
of  three  generations,  conduces  much  to  correctness  01 
judgement  in  any  case  under  examination.  If  the 
grandparents  on  both  paternal  and  maternal  sides  have 
reached  old  age  the  risk  is  more  desirable.  Longevity 
of  grandparents  on  the  maternal  side  is  to  be  preferred 
to  that  on  the  paternal  side.  In  either  instance,  if 
possible,  the  cause  of  the  death  of  the  grandparents 
should  be  noted.  If  either  of  them  was  affected  by 
phthisis,  or  tuberculosis  in  any  of  its  forms ;  by  apo- 
plexy or  paralysis,  by  rheumatism  or  gout;  by  organic 
disease  of  the  heart,  Bright's  disease,  cancer,  insanity 
or  epilepsy  ;  by  syphilis,  or  other  transmissible  disease, 
the  risk  must  be  most  carefully  investigated.  Mean- 
while it  should  be  recollected  that  change  of  location, 
intermarriage  and  habits,  etc.,  are  capable,  under  the 
guidance  of  the  present  developed  principles  of  hy- 
giene, of  almost  entirely  controlling  or  obviating 


the  hereditary  tendency.  All  causes  of  disease  thor- 
oughly understood  may,  not  only  be  robbed  of  their 
pernicious  tendency  but,  be  rendered  subservient  to 
the  increased  longevity  of  the  race.  It  is  to  be  recol 
lected  that  progressive  improvements  in  hygiene  and 
medical  science,  as  a  whole,  have  largely  increased  the 
relative  duration  of  human  life,  and  that  the  longevity 
of  our  grandparents  may,  cxteris  paribus,  be  well  sur- 
passed by  this  generation,  and  this  still  further  increased 
by  the  next,  by  approximation  to  recognition  of  the 
great  laws  of  health  as  now  understood. 

XIX. 

Parents  Living  or  Dead— PRESENT  HEALTH  OR 
CAUSE  OF  DEATH,  RESPECTIVELY. —  As  previously  re- 
marked, hereditary  predispositions  require  at  least 
three  generations  for  their  satisfactory  elucidation. 
But  as  one  of  these,  and  strongly  influencing  the  re- 
sult of  observation,  the  peculiarities  of  parents  should 
be  studied.  "  When  one  only  of  the  parents  is  the 
victim  of  constitutional  disease,  the  tendency  to  sim- 
ilar constitutional  diseases  is  most  obviously  expressed 
in  those  children  who  most  resemble  that  parent  in 
physical  conformation  and  appearance,  and  it  has  been 
observed  that,  when  both  parents  suffer,  the  tendency 
will  sometimes  be  expressed  more  often  in  the  daugh- 
ters of  the  family  than  in  the  sons,  or  more  often  in 
the  sons  than  in  the  daughters."  The  organic  peculiari- 
ties, derived  from  the  parent,  will  determine  special  and 
peculiar  results  from  any  accidental  exciting  cause, 


But  it  should  be  recollected  that  the  incidental  occur- 
rence of  a  family  disease  is  less  likely  to  be  marked  by 
acute,  prolonged,  or  obstinate  symptoms  than  when 
the  same  disease,  nosologically,  occurs  in  an  individual 
without  such  hereditary  predisposition.  Nevertheless, 
its  occurrence,  whether  severe  or  mild,  fully  deter- 
mines the  hereditary  proclivity,  and  impairs  the  risk. 
Family  proclivities  to  disease  are  more  strikingly  man- 
ifested in  brothers  and  sisters  than  between  parents 
and  children.  The  intermingling  of  opposite  tenden- 
cies begets,  so  to  speak,  m  the  children,  a  neutraliza- 
tion of  the  peculiar  aptitudes  to  disease  existing  in  the 
parents  respectively.  Physiological  likeness  of  the 
parents  induces  imperfect  progeny,  pro  tanto,  just  as 
certainly  as  intermarriage  within  the  forbidden  degrees 
of  consanguinity.  En  passant,  we  remark,  the  offspring 
of  cousins,  etc.,  must  be  most  carefully  examined, 
prior  to  any  recommendation  of  the  risk.  The  ques- 
tion involving  any  such  relationship  of  parents  should 
never  be  omitted. 

Tuberculosis,  carcinoma,  and  other  malignant  form- 
ations, rheumatism,  gout,  insanity,  paralysis,  apoplexy, 
syphilitic,  renal  and  cutaneous  diseases,  are  especially 
noteworthy  in  this  connection. 

In  considering  the  influence  of  hereditary  tendency 
to  disease,  the  remarks  upon  p.  6,  et  seq.y  require  at- 
tention. //  may  have  been  outgrown,  or  not  yet  arrived 
at.  No  sufficient  exciting  cause  may  have  yet  been 
presented.  The  individual  may  appear  in  high  physi- 
cal health,  and  yet  be  on  the  brink  of  disease  of  the 
most  fatal  kind. 


60 

It  is  fortunately  the  case  that  the  medical  science  of 
the  present  time  looks  largely  more  to  individual  ten- 
dencies towards  death,  and  suggests  prophylactic 
hygienic  measures,  rather  than  engages  in  a  wild  pur- 
suit of  specifics  and  mysteriously  operating  agents, 
to  do  away  with  organic  morbid  changes  already  grown 
unmanageable  and  incurable. 

The  exact  influence  of  hereditary  tendency  to  dis 
ease  can,  probably,  be  never  precisely  estimated,  be- 
cause the  vice  of  organization  inherited  will  always 
increase  the  mortality  from  other  forms,  of  disease 
The  latent  predisposition  will  manifest  itself  in  that 
increased  mortality.  Nearly  nine  out  of  ten  con- 
sumptive patients  will  be  found,  on  investigation,  to 
have  lost  one  or  two  out  of  the  immediate  family 
connexion  by  phthisis. 

A  single  instance  in  a  family  of  a  disease,  usually 
hereditary,  need  not  invalidate  the  risk.  The  party 
is  thrown  on  his  own  personality.  Both  father  and 
mother  being  of  consumptive  tendency,  the  risk 
should  be  declined.  But  either  may  have  died  of 
some  accidental  intercurrent  disease  or  injury.  Hence 
the  personal  peculiarities  shonld  be  ascertained.  The 
mother  transmits  disease  more  certainly  than  the  father. 
But  the  likeness  of  organization,  if  it  can  be  deter- 
mined, affords  the  best  method  of  general  judgment. 
When,  in  addition  to  one,  or  both,  of  the  parents,  a 
brother  or  sister  has  died  of  an,  usually,  hereditary 
disease,  the  risk  should  be  declined. 

The  author  repeats  his  carefully  considered  and 
matured  conviction,  from  the  evidences,  that  brothers 


6i 

and  sisters  are  more  likely  to  manifest  hereditary  pro 
clivities  to  disease  than  are  parents  and  children.  They 
inherit  respectively  the  faults  and  virtues,  as  well 
physical  as  mental,  of  each  of  the  parents.  How  far 
these  may  counteract  each  other,  and  produce  a  well 
balanced  mental  and  physical  organization,  it  Is  the 
duty  of  the  Medical  Examiner  cautiously  to  consider. 

In  addition  to  general  resemblance  of  external  and 
internal  organization,  it  should  be  recollected,  mem- 
bers of  the  same  family  are  likely  to  have  acquired 
similarity  of  habits  of  living,  diet,  dress,  exercise, 
exposure,  etc.,  which  cannot  fail  respectively  to  im- 
press upon  them  similar  tendencies  to  health  or 
disease. 

In  this  relation,  also,  it  is  well  to  bear  in  mind  the 
physiological  fact  that  half-brothers,  or  half-sisters, 
may  indicate  individual  tendencies  to  organic  change 
which  may  throw  light  on  the  constitutional  peculiari- 
ties of  the  party  under  examination.  The  second 
husband  may  not  solely  be  responsible  for  the  organi- 
zation of  his  own  children.  This  point,  it  must  be 
confessed,  is  one  surrounded  by  obscurity,  but  the 
indefatigable  medical  agent  of  a  life  insurance  society 
may  derive,  from  the  most  unexpected  quarters, 
evidences  to  guide  him  in  forming  an  unexceptionable 
and  reliable  opinion. 

XX. 

Family  Physician, —  The  Examiner  should  never 
neglect  observance  of  this  query.  First,  that  he  may 
have  t^e  testimony  of  the  attendant  medical  man  as 


62 

to  any  peculiarities  observed  in  previous  diseases. 
Clear-headed  medical  men,  in  cases  treated  by  them, 
gain  cognizance,  not  only  of  present  severe  symptoms, 
but,  what  is  of  more  importance,  of  the  tendencies 
towards  a  particular  form  of  death.  Some  physicians, 
and  a  great  deal  of  cheap  rhetoric  has  been  expended 
upon  this  point,  complain  that  insurance  companies  do 
not  pay  them  for  the  information  conveyed  in  their 
certificate.  This  is  simply  absurd.  The  family  physi- 
cian is  the  friend  of  the  party  applying,  and,  it  is  fair 
to  presume,  has  relations  with  the  party  not  altogether 
of  the  eleemosynary  kind.  The  trouble  of  filling  out 
the  certificate  is  merely  trivial,  being  altogether  his- 
torical in  its  nature.  Yet  it  is  of  value  —  not  solely 
to  the  company.  Doubtful  points  may  be  thereby 
explained,  and  difficulties  cleared  up.  The  professional 
character  of  the  physician,  it  is  needless  to  say,  lends 
much  of  confidence  to  the  examiner  in  making  up 
his  opinion.  Aside  from  his  certificate,  his  attendance 
upon  the  party  may  lessen  (or  increase)  the  dangers 
of  accidental  disease.  One  or  two  companies  adver- 
tise a  reduction  of  rates,  even  so  much  as  ten  per  cent.^ 
provided  a  particular  species  of  family  <c physician"  is 
employed.  This  would  be  startling  to  life  companies, 
and  examiners  generally,  were  it  not  so  clearly  an 
advertising  device — the  expense  to  be  defrayed  by 
diminished  dividends  to  the  insured. 

XXI. 

Intimate  Friend  Referred  to,  —  There  may  be  cir- 
cumstances affecting  the  prospects  of  longevity  which 


63 

the  applicant  is  either  ignorant  of,  or  wilfully  with- 
holds. Thus,  habits  of  intemperance  are  most  fre- 
quently of  all  denied  by  the  party  himself,  and  these 
may  be  made  known  by  his  acquaintances.  The 
solicitor  ought  not  to  neglect  inquiry  upon  this  point, 
and  submit  to  the  examiner  the  friend's  certificate. 

Again,  the  applicant  may  have  had  "fits" — epileptic 
or  apoplectic  seizure,  etc.,  the  real  significance  of  which 
may,  for  prudential  or  other  reasons,  have  been  with- 
held from  his  knowledge.  For  these  and  similar 
reasons,  the  corroborative  evidence  thus  gained,  should 
be  laid  before  the  examiner. 

XXII- 

Previous  Rejection  or  Assurance, —  The  fact  of 

previous  insurance  should  never  be  permitted  to  lessen 
the  care  of  inspection.  The  previous  examiner  may 
have  been  inexpert  or  careless,  or  have  inadvertently 
overlooked  some  important  point.  Or,  again,  acute 
or  chronic,  or  even  hereditary  diseases,  may  have  since 
been  developed,  involving  organic  changes  of  imme- 
diate or  remote  danger.  Previous  rejection  demands 
employment  of  all  the  physician'  s  skill  in  diagnosis. 
The  real  cause  for  such  rejection  should  be  discovered, 
if  possible.  It  may  have  been  in  consequence  of  the 
applicant's  then  habits,  and  some  other  reason  assigned 
to  spare  personal  feeling.  It  may  have  been  from 
some  temporary  ailment  present,  or  not  yet  fully  re- 
covered from.  It  may  have  been  from  misapprehen- 
sion of  the  applicant's  answers  on  certain  points,  or 
from  misinterpretation  of  symptoms  observed.  Or, 


64 

again,  because  the  company  to  .which  application  was 
made,  excluded  a  particular  class  of  cases  whicn  other 
companies  accept.  Or,  by  the  baldest  hypothesis,  it 
may  have  been  from  the  human  weakness  of  attempting 
to  gain  credit  for  remarkable  professional  skill  and 
acumen,  at  a  cheap  rate. 

But  when  the  previous  examiner  and  the  attendant 
circumstances  are  fully  known,  nothing  but  positive 
demonstration  will  warrant  the  medical  man  in  recom- 
mending the  risk.  It  must  be  demonstrated  that  the 
previous  disease  is  fully  recovered  from ;  that  the 
hereditary  taint  is  absent ;  that  bad  habits  do  not 
exist ;  that  the  heart  or  lungs,  or  other  organ  blamed, 
are  respectively  free  from  lesion.  Whilst  a  needless 
••ejection  does  permanent  injustice  to  both  the  appli- 
cant and  the  company,  every  medical  examiner  must 
avoid  the  imputation  of  making  the  company  by  whom 
he  is  engaged,  a  hospital  for  invalid  risks. 

XXIII. 

Is  the  Applicant  fully  Aware  OF  THE  PURPORT  OP 

THE  QUESTIONS  HE  HAS  ANSWERED  AND  SUBSCRIBED? 
He  may  be  of  limited  intelligence,  or  unfamiliar  with 
the  language,  the  names  of  the  diseases  alluded  to, 
etc.  The  solicitor  may  have  been  careless  in  his 
method,  and  thus  periled  the  party's  subsequent 
rights,  as  well  as  tending  to  mislead  the  examiner. 

Wherever  there  is  the  slightest  cause  to  apprenend 
any  negligence  or  mistake  in  this  matter,  the  exam- 
iner should  himself  again  propound  the  necessary 
questions. 


THE  EXAMINATION. 


In  order  that  no  point  may  be  overlooked,  the 
Medical  Examiner  should  adopt  a  regular  method  of 
personal  examination  of  the  applicant  —  the  form 
adopted  by  the  company  for  which  he  acts  being  care- 
fully adhered  to,  but,  nevertheless,  considered  merely 
as  suggestive,  not  exhaustive.  All  the  considerations 
noticed  in  the  Applicant's  personal  history,  must  be 
given  full  weight  in  the  proposition  of  further  ques- 
tions, and  still  more  careful  observation.  Although 
not  in  accordance  with  the  usual  mode  of  systematic 
general  diagnosis,  the  purposes  of  this  essay  will, 
perhaps,  be  better  subserved  by  adhering  to  the  more 
generally  adopted  formulae  furnished  by  the  insurance 
companies. 

Be  sure  that  the  person  examined  is  the  one  whose 
application  has  been  read  over.  Mistakes  here  occa- 
sionally occiar,  especially  when  parties  have  the  same 
names,  or  several  applications  are  received  at  once. 
These  blunders  might  be  deemed  merely  ludicrous, 
were  they  not  so  important  in  their  probable  results. 
5  6$ 


66 

I. 

Height  and  Weight — Whilst  the  general  propor- 
tions are,  perhaps,  of  the  most  importance,  yet  the 
rule  is,  that  the  medium  height  is  endowed  with  the 
greatest  endurance.  Five  feet  and  eight  inches  may 
be  taken  as  the  medium  in  this  country,  for  adult 
males.  The  average  of  adult  females  is,  of  cou?S£ 
considerably  below  this  —  but  statistics  are  wanting 
upon  the  subject.  Probably  five  feet  and  one  and  a 
half  inches  is  the  approximately  correct  standard. 
Emigrants  from  Continental  Europe  average  a  little 
less  than  five  feet  six  inches,  if  we  except  certain  races, 
as  the  Hungarians,  Poles,  and  Sclaves,  who  reach  the 
American  standard.  Emigrants  from  the  British 
Islands  average  about  five  feet  seven  inches. 

In  this  country,  the  average  height  of  persons  bred 
and  living  in  large  towns  and  cities,  is  something  less 
than  that  of  those  living  in  rural  districts,  whilst  in 
Enrope,  the  reverse  is  claimed  to  be  the  case.  This 
fact  is  important,  as  to  a  certain  extent  indicating  the 
general  hygienic  influences  which  have  operated  on 
races,  families,  and,  ultimately,  the  individual.  The 
better  developed  having  been  from  a  better  nourished 
stock,  and  physically  superior  lineage. 

Very  tall  men  are  usually  of  less  muscular  power, 
less  respiratory  activity,  with  a  greater  tendency  to 
cardiac  and  pulmonary  diseases.  They  are  more  liable 
to  hernia,  varicose  veins,  and  ulcers  of  an  obstinate 
kind  upon  the  extremities.  Acute  diseases  attacking 
them  are  more  disposed  to  assume  the  chronic  form, 
with  general  breaking  down  of  the  constitution.  On 


67 

the  other  hand,  short  persons  are  apt  *o  be  dispropor- 
tionately developed  ;  their  muscular  power,  and  ca- 
pacity for  physical  endurance  are  small,  and  they  become 
the  ready  victims  of  acute,  and  especially  epidemic 
diseases. 

The  relation  of  age  to  the  height  ahould  never  be 
overlooked,  but  this  will  be  alluded  to  a  little  further 


THE  WEIGHT  is  of  moment,  relatively  to  the  height. 
The  simplest  statement  of  the  due  relation  is  that  of 
Dr.  Brinton  :  "  As  a  rule,  it  may  be  laid  down  that 
an  adult  male,  in  good  health,  66  inches  in  stature, 
ought  to  weigh  rather  more  than  ten  stones,  or  140 
pounds  avoirdupois.  And  for  every  inch  above  and 
below  this  height,  we  may  respectively  add  and 
subtract  about  five  pounds." 

Individuals  may  present  a  wide  range  of  variation 
from  this  ;  "But  as  a  rule,  twenty  per  cent.,  or  one- 
fifth,  is  almost  the  maximum  variation  within  the 
limits  of  health." 

The  annexed  table  is  introduced  for  convenience  of 
reference  : 

HEIGHT. 

5   feet    I    inch, 
5     "     2     " 
5 


5  " 

6  " 

7  " 

8  '« 

9  " 

10  " 

11  «' 


WEIGHT. 

MEDIUM 

CHEST. 

Should 

weigh 

1  20 

tbs 

34.06 

inch. 

ft 

tt 

125 

ft 

35-'3 

tt 

€f 

tt 

130 

tt 

35.70 

" 

ft 

tt 

135 

tt 

36.26 

" 

€€ 

tt 

140 

tt 

36.83 

tt 

M 

" 

H3 

tt 

37-50 

tt 

(f 

tt 

HS 

tt 

38.16 

" 

ft 

ft 

148 

tt 

38.53 

tt 

ft 

tt 

155 

tt 

39.10 

tt 

ft 

tt 

1  60 

tt 

39.66 

tt 

" 

ft 

165 

tt 

40.23 

ft 

€€ 

tt 

170 

tt 

40.80 

1C 

68 

The  maximum  of  height  is  usually  reached  at 
twenty- five  —  the  rate  of  progress  being  about  ten 
inches  from  eleven  to  eighteen,  and  two  inches  only 
from  that  age  to  maturity.  An  increment  much 
surpassing  this  during  the  latter  epoch  is  a  suspicious 
circumstance,  and  unless  accompanied  by  apparent 
coincident  development  of  the  nutrient  energy,  and 
correspondent  increase  of  weight,  impairs  the  risk. 

Excessive  obesity  at  any  period  vitiates  the  risk, 
and  particularly  where  it  has  come  on  within  a  com- 
paratively brief  period.  After  the  age  of  complete 
maturity,  usually,  there  is  a  deposit  of  adipose  tissue 
which  largely  increases  the  relative  proportion  of  the 
weight  to  the  height ;  and  if  this  occurs  gradually  and 
if  clearly  traceable  to  hereditary  peculiarity  it  does 
not  disparage  the  risk.  But  the  rapid  occurrence  of 
corpulence  points  almost  infallibly  to  deterioration  of 
nutrition,  the  result  of,  it  may  be,  newly  formed 
sedentary  habits,  intemperance,  internal  organic  disease, 
or  that  general  cachexia  which  accompanies  fatty 
degenerations. 

On  the  other  hand  emaciation  slow  and  progressive 
after  middle  life,  if  clearly  a  family  characteristic  does 
not  necessarily  disqualify,  although  it  demands  close 
investigation.  Rapid  emaciation,  even  without  apparent 
organic  cause,  rejects/ 

Incidentally  it  may  be  remarked,  that  measurement 
of  the  chest  will  afford  an  index  of  the  relative  pro- 
portions of  the  height  and  weight.  The  rule  suggested 
by  Brent  is  sufficiently  exact.  Measured  over  the 
nipples : 


6g 

Minimum  chest:  half  of  the  stature,  minus  one-sixty- 
first  of  the  stature,  is  equal  to  circumference  of  the 
chest. 

Medium  chest :  half  of  the  stature,  plus  one-fifteenth 
of  the  stature,  is  equal  to  circumference  of  the  chest. 

Maximum  chest:  two- thirds  of  the  stature  is  equal 
to  circumference  of  the  chest. 

Irrespective  of  the  height,  the  general  statement  is 
authorized  that  <c  the  circumference  of  the  chest  in- 
creases exactly  one  inch  for  every  ten  pounds  increase 
of  weight." 

If  these  proportions  are  widely  departed  from,  the 
case  requires  research  as  to  the  cause  of  the  unusual 
deposit. 

So,  also,  local  emaciation  suggests  similar  caution. 
Incipient  phthisis  generally  is  denoted  by  wasting  of 
the  tissues  of  the  thorax  and  of  the  arms,  long  before 
it  is  to  be  observed  in  the  face  or  lower  extremities. 

At  the  present  time,  when  a  large  proportion  of 
the  adult  males  wishing  to  be  insured  have  recently 
returned  from  the  exposures  of  army  life,  it  is  well  to 
bear  in  mind  that  diminished  weight  is  one  of  the 
most  significant  evidences  of  chronic,  and  possibly, 
painless  diarhcea. 

n. 

General  Appearance,  —  The  proportionate  height 
and  weight  with  the  more  or  less  symmetrical  develop- 
ment of  the  body,  as  a  whole,  make  up  a  part  of  the 
general  appearance ;  but  beyond  this  the  attention  of 
the  examiner  is  to  be  directed  to  various  details  which 


7o 

go  to  make  up  the  tout  ensemble.  Among  these  we 
specify :  Aspect  of  the  Countenance,  Complexion,  Color 
of  the  Hair  and  Eyes,  Size  of  the  Bones,  Contour  of 
Muscles,  Gait,  Apparent  Age,  Temperament,  Idiosyncrasy. 

ASPECT  OF  COUNTENANCE. — Experienced  observers 
readily  recognize  in  diseases  a  physiognomy  peculiar 
to  each,  always  difficult  and  often  impossible  satisfac- 
torily to  describe,  nevertheless  so  distinguishable  as  to 
be  worthy  of  serious  consideration  in  judging  of  a  risk. 
By  this  observation  they  can  ultimately  decide,  almost 
as  quickly  as  an  expert  cashier  upon  the  genuineness 
of  a  signature  or  bank  note.  But  this  acquired  skill 
and  readiness  never,  when  such  large  interests  are  in 
issue,  should  be  relied  upon  to  the  exclusion  of  those 
rigid  tests  by  which  the  opinion  may  be  solidified  into 
an  unassailable  judgment.  We  notice  here  a  few  only 
of  the  more  striking  facts,  as  indicating  the  direction 
of  observation. 

The  aspect  may  inform  of  tuberculous  cachexia  by 
the  delicate  skin,  tumid  upper  lip,  long  eyelashes, 
pearly  conjunctiva,  etc.  Or  it  may  denote  the  can- 
cerous diathesis  by  its  sallow  anaemic  hue  intermingled 
with  muscular  markings,  indicating  frequently  recur- 
ring or  continuous  pain,  or  of  that  organic  pain  of  which 
consciousness  as  yet  takes  no  note,  but  which  equally 
calls  into  action  the  reflex  sympathies  of  the  nervous 
apparatus. 

Hepatic  disease,  with  its  more  or  less  yellow  tinge 
and  hypochondriacal  look.  Or  renal  affection,  with 
its  puffy  eyelids,  sodden  or  waxy  skin,  and  features 
cither  downcast  or  stolid  and  apathetic. 


7' 

Hypertrophy  of  the  heart,  with  its  unnatural  fulness 
and  congestion,  or  the  same  look  from  habitual  intem- 
perance. Or  the  facial  muscles  may  be  permanently 
contracted  in  forms  which  indicate  the  continuous  suf- 
fering of  wasting  local  or  general  disease.  Lesions 
affecting  the  nervous  centres  may  find  here  their 
earliest  exponent.  The  countenance,  which  tranquil 
shows  no  disorder,  when  wakened  by  movement  may 
give  warning  of  coming  paralysis.  Or  the  furtive 
glance  from  the  eyes,  notwithstanding  immobility  of 
the  other  features,  may  warn  of  impending  insanity. 
Or  the  rapid  transitions  in  expression,  flashing  or 
wandering  and  unsteady  eyes  may  indicate  a  different 
form  of  the  same  malady.  Or  the  whole  face  may  be 
dull  and  listless,  the  eye  sluggish,  and  the  physiog- 
nomy of  softening  of  the  brain  be  almost  beyond 
mistake. 

COMPLEXION,  —  This  should  be  noticed  as  going  to 
make  up  the  temperament  hereafter  to  be  considered. 
But  any  peculiarities  in  hue  which  it  may  have  derived 
from  antecedent  or  present  disease  or  exposure  should 
be  noted,  whether  rendered  sallow  by  residence  in 
malarious  districts,  bronzed  by  exposure  or  Addison's 
disease,  unnaturally  florid  by  intemperance  or  cardiac 
lesion,  livid  by  imperfect  aeration  of  the  blood  from 
whatever  cause,  or  "  compounded  of  alabaster  and  the 
rose"  by  incipient  phthisis,  or  pallid  and  sodden  from 
albuminuria  and  anaemia. 

COLOR  OF  THE  HAIR  AND  EYES.  —  This  point  also 
refers  particularly  to  the  temperament ;  but  attention 
is  called  here  to  changes  in  the  color  of  the  hair  from 


72 

advancing  or  premature  age ;  to  its  nutrition,  whether 
drv  and  husky  or  soft  and  silken  in  texture  —  whether 
it  remains  firmly  rooted  or  has  fallen.  These  obser- 
vations may  give  a  clue  to  the  diathesis  or  cachexia 
present. 

The  movements  of  the  eye,  its  expression,  the  con- 
dition of  the  pupil,  contracted  or  dilated,  or  whether 
these  changes  are  symmetrical ;  whether  there  be 
complete  or  partial  amaurosis  of  either ;  the  arcus 
senilis,  etc. 

It  will  be  found  that  the  eyes  can  afford, vastly  more 
information  than  merely  as  to  their  color. 

SIZE  OF  THE  BONES.  —  A  strong  bony  framework  is 
usually  connected  with  strength  of  the  nutrient  system, 
and  is  indicative  of  a  constitution  capable  of  much  en- 
durance. Prominence  of  the  apophyses  is  an  index, 
generally,  of  a  fully  developed  muscular  system  with 
its  concurrent  advantages.  But  reference  to  the  osse- 
ous system  involves  more  than  simple  observation  of 
the  size  of  the  bones  and  their  normal  projections.  It 
suggests  inquiry  into  the  perfection  of  ossification 
about  the  cranium  and  vertebral  column,  original  or 
acquired  deformity,  rachitis,  mollifies  ossium,  curvatures 
of  the  spine,  gibbosity,  &c.,  fragility,  caries,  necrosis, 
morbid  growths,  etc. 

CONTOUR  OF  MUSCLES. —  Closely  allied  in  prognos- 
tic meaning  to  the  development  of  the  bones,  will  be 
found  the  firmness  and  abundance  of  t.ie  muscular 
fibre.  The  deposit  of  adipose  tissue  will  often  ob- 
scure the  strong  lines  which  mark  the  boundaries  of 
the  muscles,  but  their  compact  structure,  contractil- 
ity and  tonicity  can  readilv  be  observed.  The  well 


73 

rounded  and  well  developed  muscular  system  renders 
the  risk  more  desirable,  as  the  feeble,  ill  developed 
fibre  suggests  the  reverse. 

Attention  is  here  directed  to  local  paralysis,  which 
may  be  present  as  the  result  of  lead  or  other  poison- 
ing, central  or  excentric  affections  of  the  nervous  sys- 
tem, &c.  Or  again,  tonic  or  clonic  spasms,  tremors, 
tremulousness,  chorea,  &c. 

APPARENT  AGE. —  The  applicant  having  recorded 
his  age,  it  is  proper  to  compare  his  apparent  with  his 
actual  age.  Some  are  really  older  at  forty  than  others 
at  sixty.  Premature  old  age  may  be  from  hereditary 
or  congenital  imperfection  of  structure,  or  it  may  be 
the  evidence  of  previous  sickness,  long  continued  ill 
health,  irregular  or  dissipated  habits,  overwork,  expo- 
sure and  the  like.  As  a  general  rule,  when  the  appli- 
cant is  really  older  than  he  looks  to  be,  his  life  expec- 
tation surpasses  the  average ;  but  when  he  has  aged 
beyond  his  years,  the  risk  is  thereby  in  so  far  impaired. 

TEMPERAMENT. —  In  noting  the  temperament  it  is 
better  to  adopt  the  simplest  possible  varieties,  recol- 
lecting that  the  phrase  is  employed  simply  to  express 
the  preponderance  in  activity  of  certain  organs  or  ap- 
paratuses in  the  individual.  Practically  four  tempera- 
ments may  be  recognized  for  purposes  of  description, 
the  Sanguine^  Bilious  or  Sarcous,  Phlegmatic  or  Lymphat- 
ic,  and  the  Nervous. 

The  Sanguine  temperament  is  characterized  by  great 
activity  of  the  blood  making  .organs,  rapid  integral 
changes  and  free  excretion.  Activity  of  mental  and 
muscular  movements,  delicacy  of  the  skin,  etc.,  are  in- 
cidental to  these.  Light  or  sandy  hair,  blue  eyes,  florid 


74 

complexion  and  the  like  are  accidental,  not  necessary 
concomitants,  being  frequently  conjoined  with  the 
other  temperaments. 

The  Phlegmatic  temperament  shows,  nearly  an  oppo- 
site condition  of  the  organism.  There  is  slow  and 
imperfect  nutrition — the  blood  tardily  developed  and 
assimilation  comparatively  feeble.  Hence  languor  of 
both  mind  and  muscle,  infrequent  and  compressible 
pulse,  flabby  and  soft  texture,  with  abundant  adipose 
deposit. 

The  Bilious  temperament  is  characterized  by  great 
perfection  of  assimilation,  but  not  remarkable  energy 
of  digestion.  The  blood  making  processes  are  not  as 
active  as  in  the  sanguine,  because  there  is  less  of  waste 
The  quantity  of  excreta  is  also  less.  Firmness  and 
strength  of  muscle  characteristically  predominate. 
The  less  rapidly  changing  skin  assumes  a  darker  hue, 
and  with  its  appendages,  hair,  nails,  &c.,  is  drier  and 
harsher.  Coincidently  the  liver  and  subsidiary  organs 
are  largely  taxed,  for  the  recomposition  of  blood  defi- 
ciently renewed  by  food. 

The  Nervous  temperament,  with  deficient  digestive 
energy  and  muscular  development,  manifests  a  striking 
activity  of  the  so  called  nervous  processes.  "  The 
countenance  is  usually  pale  and  the  features  thin  and 
sharp,  the  pulse  is  quick,  small  and  frequent ;  the  res- 
piration active  ;  the  chest  not  largely  developed  ;  the 
skin  dry  and  rough."  These  are  the  incidents  of  the 
organic  peculiarities  before  noted. 

Each  of  these  temperaments,  it  is  of  course  under- 
stood, may  be  modified  in  its  manifestations  by  a  com- 
bination with  one  of  the  others  —  a  result  not  unlikelv 


75 

to  occur  when  the  parents  have  been  of  dissimilar 
temperaments.  But  almost  typical  specimens  are 
afforded  by  families,  and  even  tribes  or  races,  when 
intermarriage  has  been  restricted  within  narrow  limits. 
Jn  this  country  where  individuals  of  the  most  diverse 
nationality  and  parentage  are  cc  marrying  and  giving  in 
marriage/'  it  is  constantly  becoming  more  difficult  tp 
assign  the  proper  status  in  this  regard.  The  point  to 
be  kept  in  mind  is,  not  the  accidents  of  color,  shape, 
&c.,  but  the  preponderant  activity  of  special  organs 
and  processes.  Thus  the  child  always  approximates 
the  sanguine ;  the  adult,  at  maturity,  the  sarcous,  and 
in  the  decline  of  life  lapses  into  the  nervous  or  phleg- 
matic, according  to  the  peculiar  organization. 

Relative  to  life  assurance,  the  matter  becomes  of  im- 
portance, as  evincing  proclivities  to  particular  forms 
of  disease.  This  is  noteworthy  when  there  exists  any 
hereditary  or  acquired  predisposition  thereto,  or  when 
the  occupation,  habits,  residence,  &c.,  renders  the  party 
liable  to  the  usual  exciting  causes.  The  sanguine  tem- 
perament predisposes  to  miasmatic  diseases,  typhoid 
and  remittent  fevers,  the  exanthems,  to  acute  rheuma- 
tism, organic  and  functional  diseases  of  the  heart  and 
arteries,  to  haemorhages  and  under  conditions  unfavor- 
able to  nutrition  to  tuberculosis. 

The  phlegmatic  temperament  on  the  contrary  pre- 
disposes to  chronic  and  often  incurable  inflammations, 
dropsies  and  fluxes  of  various  kinds,  especially  from 
mucous  membranes,  influenza  and  scrofulosis. 

The  bilious  temperament  favors  the  occurrence  of 
endemic  disease,  febrile  affections  tending  to  a  low 


76 

grade,  hepatic  obstruction  with  dysentery,  haemor- 
rhoids, fistula  in  ano.  &c.  When  rheumatism  occurs 
in  this  organization  the  heart  rarely  escapes  being  in- 
volved sooner  or  later. 

The  nervous  temperament  involves  liability  to  in- 
sanity, epilepsy,  paralysis  and  neuroses  generally.  If 
typhoid  fever  happens  to  such  an  one  the  issue  is  very 
dangerous. 

In  taking  note  of  the  GENERAL  APPEARANCE  any 
IDIOSYNCRASY  present  deserves  careful  attention  and  its 
possible  bearing  upon  the  life  prospects  of  the  party  must 
be  noted,  Idiosyncrasies  vary  so  remarkably  in  their 
characters  that  it  is  unnecessary  to  do  more  than  sim- 
ply direct  notice  to  the  fact  that  they  are  capable  cf 
largely  modifying  particular  indications,  and  indeed 
the  ultimate  judgment. 

ii. 

The  Pulse  demands  attention  to  its  frequency, 
rhythm  and  general  character.  Indications  derived 
from  it  require  analysis  to  be  at  all  satisfactory. 

The  normal  pulse  described  by  authors  for  the 
adult  male  ranges  in  frequency  from  sixty-eight  to  sev- 
enty-two ;  more  frequent  in  infancy,  childhood  and 
youth  —  again  rising  in  frequency  in  advanced  age, 
although  gradually  diminishing  from  maturity  to  per- 
haps sixty  or  seventy.  It  is  slower  in  the  morning 
than  in  the  evening.  It  is  more  frequent  in  the  erect 
position  than  when  sitting,  and  still  less  rapid  when 
recumbent.  It  is  hastened  by  nervous  excitement  or 
muscular  exercise.  .  Any  tension  of  the  contractile 


77 

fibre  will  easily  cause  it  to  rise  from  the  usual  stand- 
ard to  even  double  its  ordinary  rate,  In  fine  it  is 
rather  an  index  of  the  nervous  system  than,  as  formerly 
supposed,  of  circulatory  energy. 

The  pulse  of  Great  Britain  and  Continental  Europe 
ranges  from  sixty-eight  to  seventy-two,  but  that  of 
the  Atlantic  States  of  America  from  seventy-two  to 
seventy-six,  while  that  of  the  Northwest  will  rarely  be 
less  than  seventy-six  to  eighty.  A  pulse  uniformly, 
or  even  temporarily,  below  sixty  or  above  ninety  must 
be  explained  by  idiosyncrasy,  or  else  it  rejects — at  the 
best  postpones  judgement. 

The  irregular  pulse  must  be  likewise  demonstrated 
to  be  an  individual  characteristic;  otherwise  it  rejects. 
Unexplained  it  is  totally  exclusive. 

The  intermittent  pulse  calls  attention  to  probable 
cerebral  or  cardiac  disease.  Occasionally  it  is  the  re- 
sult of  temporary  gastric  or  other  local  disorder ;  but 
even  then  it  should  cause  suspension  of  judgment. 
The  rate  of  the  pulse  should  be  recorded  when  the 
applicant  is  sitting,  or,  better,  the  difference  in  rate 
between  the  two  positions  should  be  given. 

The  hammering  pulse  emphatically  calls  attention  to 
the  cardiac  valves. 

The  general  character  of  the  pulse  is  expressed  by 
the  terms  full,  free,  hard,  soft,  weak,  etc. 

While  considering  the  pulse  the  whole  arterial  sys- 
tsm  should  be  taken  under  review.  Unnatural  or  ex- 
traordinary hardness  possibly  indicative  of  senile  or 
calcareous  degeneration  of  the  arterial  parietes,  to  u*~ 
timate  in  aneurism,  senile  gangrene  or  embolism. 

But  the  pulse  is  fallacissima  rerum 


78 

III. 

The  Respiratory  Organs.— A  fully  developed  and 

powerful  thorax  is  one  of  the  best  evidences  of  gene- 
ral physical  capacity  and  endurance,  whilst  a  narrow, 
contracted  or  malformed  chest  is  a  strong  evidence  of 
a  feeble  constitution.  The  methods  of  investigation 
differ  somewhat  in  details,  but  all  coincide  in  essen- 
tials. 

MENSURATION. —  Some  details  have  already  been 
given  (p.  56  et  ^.,)as  to  the  relation  of  the  circumfer- 
ence of  the  chest  to  the  height  and  weight.  It  is  well 
to  bear  in  mind  that  due  proportion  requires  that  the 
circumference  should  equal  twice  the  distance  between 
the  angles  of  the  shoulders ;  that  it  should  be  four 
times  the  antero-posterior  diameter  at  the  lower  por- 
tion of  the  sternum,  and  that  this  latter  diameter 
should  exactly  equal  the  distance  between  the  nipples. 

Practically,  measurement  is  best  made  with  the  sim- 
ple graduated  tape  line,  which  adapts  itself  readily  to 
the  surface  and  can  be  always  carried  in  the  pocket. 
For  physiological  investigations  other  instruments  may 
be  of  service,  but  are  unnecessary  here.  The  line 
should  be  applied  under  the  vest,  if  practicable,  at  the 
level  of  the  nipples,  and  on  the  same  plane  anteriorly 
and  posteriorly.  If  taken  over  the  vest,  or  there  is 
much  clothing  beneath  the  tape,  a  suitable  allowance 
must  be  made  therefor. 

Note  now  the  measurement : 

I  st.  During  the  largest  inspiration. 

ad.   During  forced  expiration. 


79 

3d.  During  tranquil  respiration  about  the  middle 
of  inspiration. 

The  first  and  second  measurements  give  a  clue  to 
the  capacity  of  the  lungs  for  the  "  complemental "  air 
or  extreme  vital  capacity,  whilst  the  third  suggests  the 
amount  of  "  tidal "  or  ordinary  breathing  air,  which  is 
perhaps  of  equal  importance,  as  exhibiting  the  indi- 
vidual's present  condition.  A  man  five  feet  eight 
inches  should  have  a  breathing  capacity  of  230  cubic 
inches  of  air,  while  in  point  of  fact,  in  tranquil  respi- 
ration there  is  not  usually  a  change  of  over  20  or  30 
cubic  inches  within  the  lungs.  Nevertheless  the  phys- 
ical capacity  for  large  aeration  of  the  blood  adds  to 
the  desirability  of  the  risk. 

The  extreme  breathing  capacity  is  increased  eight 
cubic  inches  for  every  additional  inch  of  stature  be- 
tween five  and  six  feet,  when  due  proportion  is  main- 
tained. If  this  proportion  is  not  maintained  the  risk 
is,  in  so  far,  impaired. 

Observations  made  with  the  spirometer,  although 
interesting  in  a  physiological  point  of  view,  are  prac- 
tically of  no  avail  to  the  insurance  examiner.  Inci- 
dentally it  may  be  observed  that  the  extreme  breathing 
capacity  is  diminished  by  obesity ;  that  it  is  propor- 
tionately less  in  females  than  in  males,  and  in  children 
than  in  adults.  The  volume  increases  with  age  to  the 
thirtieth  year,  and  gradually  decreases  from  thence  to 
the  decline  of  life.  A  deficiency  from  the  normal 
standard  of  sixteen  per  cent,  is  suspicious,  and  if  very 
much  below  this  will  invalidate  the  risk.  Coincident 
signs  or  symptoms  under  such  circumstances,  will  al- 
most invariably  confirm  indications  on  this  point. 


8o 

The  average  expansion  in  full  respiration  will  be 
found  to  be  a  little  over  three  inches,  but  in  tranquil 
respiration  it  is  scarcely  more  than  an  inch.  The  right 
side  expands  a  little  more  than  the  left,  as  it  is  gener- 
ally, in  right  handed  persons,  a  little  over  half  an  inch 
largest.  Any  variation  from  the  normal  amount  of 
expansion  at  any  part  of  the  chest  should  be  noted, 
and  its  cause  sought  out. 

INSPECTION. —  The  general  form  of  the  chest  will 
suggest  particular  observation.  Thus,  whether  there 
be  any  flattening,  especially  in  the  clavicular  regions, 
or  even  across  the  whole  anterior  surface,  with  stoop 
mg  shoulders,  curved  sternum  and  projecting  inferior 
angles  of  the  scapulae  —  collectively  indicative  of  fee- 
bleness of  constitution,  slight  power  of  endurance, 
and  proneness  to  tubercular  deposit. 

Flattening  of  the  lateral  or  inferior  portions,  signifi- 
cant of  old  pleurisy  with  remaining  adhesion,  or  of  old 
abscesses,  &c. 

Again,  deficient  transverse  diameter  with  projection 
of  the  sternum,  or  "chicken-breast,"  suggestive  of 
causes  of  dyspnoea  in  early  life,  or  perhaps  now  pres- 
ent, or  again,  of  rachitis,  &c.  The  chicken-breast  is 
ordinarily  indicative  of  deficient  vital  capacity,  and  al- 
though not  seemingly  productive  of  inconvenience, 
may,  nevertheless,  like  "  hunchback,"  militate  against 
the  risk. 

RESPIRATORY  MOVEMENTS. — The  frequency,  rhythm 
and  type  of  motion  in  inspiration  and  expiration  are 
to  be  noted. 

In  the  adult  male,  during  tranquil  breathing,  the 
average  frequency  of  inspiration  may  be  placed  at  from 


Si 

fifteen  to  twenty  per  minute,  or  about  17,  but  the 
slightest  mental  influences  or  exercise  will  vary  this 
widely.  Probably  the  point  of  most  importance  is  the 
ratio  to  the  pulse,  which  should  be  very  closely  as  one 
to  four  or  five.  The  movements  should  be  noted 
while  numbering  the  pulse,  and  the  ratio  then  ob- 
served. Nevertheless,  as  a  rule,  if  the  respiratory  acts 
are  less  frequent  than  twelve  or  more  than  twenty- 
four,  decision  should  be  suspended.  It  is  to  be  recol* 
lected,  as  Walshe  observes,  that  the  rapidity,  energy 
and  extent  of  these  movements  "  increase  in  the  direct 
ratio  of  the  easy  mobility'  of  the  framework  of  the 
chest  (hence  greater  in  youth  than  age,)  and  the  height 
of  the  individual."  In  females,  generally,  and  in 
males  of  a  nervous  temperament,  the  frequency  is  ex- 
aggerated easily,  and,  as  a  rule,  slowness  of  these 
movements  is  a  more  objectionable  feature  than  its 
opposite.  But  coincident  evidence  will  usually  ex- 
plain satisfactorily  the  cause. 

The  fifth  expiration  (on  the  average,)  is  a  little  deep- 
er than  the  others.  The  ratio  of  inspiration,  expira- 
tion and  quiescence  should  be  about  as  five,  four  and 
one  respectively, 

If  the  motions  are  irregular,  intermittent  or  jerking, 
the  case  requires  scrutiny.  If  the  ratio  is  widely  de- 
parted from,  further  investigation  is  demanded,  partic- 
ularly where  expiration  is  prolonged — the  latter  symp- 
toms awakening  great  anxiety.  The  irregular,  inter- 
mittent or  jerking  respiration  is  usually  indicative  of 
derangement  of  the  nervous  system,  but  prolonged  ex- 
piration minatory  of  local  lesion  of  the  lungs.  It 
6 


82 

may  become  more  than  twice  the  length  of  the  inspi- 
ration. 

The  type  should  be  abdominal  in  the  infant,  dia- 
phragmatic and  inferior  costal  in  the  adult  male ; 
superior  costal  in  the  adult  female.  Any  change  of 
these  types  is  suspicious.  Notably  so  pectoral  breath- 
ing of  marked  character  in  the  man,  and  even  in  the 
woman,  when  exaggerated  and  accompanied  by  a  per- 
perceptible  rising  of  the  shoulders  with  each  inspi- 
ration. 

DISEASES. —  Acute  diseases  of  the  respiratory  or- 
gans postpone  and,  after  apparent  cure,  demand  search 
for  lesions  left  behind.  Catarrh,  Pharyngitis,  Lar* 
yngitis,  Tracheitis  and  Bronchitis  do  not  necessarily 
involve  a  tendency  to  Phthisis  Pulmonalis,  but  their 
frequent  recurrence  gives  grave  doubts,  which  must  be 
cleared  up  before  insurance.  If  they  assume  the 
chronic  form,  it  becomes  imperative  to  demonstrate 
the  absence  of  the  tuberculous  taint.  Or  perhaps  they 
may  be  the  sole  exponents  of  Syphilis  or  other  cachexia, 

Ulceration  of  the  larynx  is  about  infallibly  an  evi- 
dence of  tuberculosis  or  syphilis. 

A  slight  catarrhal  condition  of  the  respiratory  mu- 
cous membrane  may  have  become  habitual,  and  in  the 
assured  absence  of  any  constitutional  cachexia,  or  he- 
reditary tendency,  need  not  preclude  the  risk,  although 
placing  it  in  lower  grade. 

But  the  attention  of  the  Examiner  is  with  greater 
earnestness  called  to  the  more  prominent  affections 
which,  when  decided  to  be  present,  must  necessarily 
induce  him  to  decline  the  risk. 


As  tnis  is  not  intended  as  a  systematic  treatise  on 
nosology  or  diagnosis,  for  convenience  I  shall  consider 
these  affections  in  alphabetical  order. 

ADHESIONS  of  the  pleural  surfaces  often  occur  with- 
out noticeable  morbific  results.  It  is  important  to 
recognize  the  condition  so  as  not  to  confound  such 
signs  as  it  may  afford  with  those  of  a  graver  character. 
They  impair  the  mobility  of  the  parietes,  and  occa- 
sionally that  of  the  arm  of  the  affected  side.  Flatten- 
ing or  contraction,  more  or  less  discernible,  usually 
of  the  lower  and  lateral  parts  of  the  chest ;  feeble 
respiration  ;  very  slight  diminution  of  resonance  ;  no 
bronchophony  or  augmented  vocal  fremitus ;  inter- 
rupted respiration,  but  not  prolonged  expiration 
Diagnosis  will  be  materally  assisted  by  noting  his- 
torical symptoms  and  absence  of  tuberculous  diathesis. 
Unless  the  pleurisy  has  become  chronic,  or  the  adhe- 
sion is  so  extensive  as  to  materially  impair  the  breath- 
ing capacity,  this  condition  need  not  necessarily  reject, 
but  assigns  to  a  lower  grade.  When  the  results  are 
seen  at  the  superior  portion  of  the  lobes,  its  almost 
certain  coincidence  with  tuberculous  deposit  and  result- 
ing inflammation,  necessitates  rejection. 

ASTHMA  has  already  been  noticed,  (p.  17,  et  j^,)but 
when  the  party  has  wilfully  or  negligently  concealed 
its  previous  occurrence,  it  may  often  be  detected  by  its 
peculiar  dry  wheezing  or  sibilant  whistle,  even  during 
the  interim.  The  affections  upon  which  it  may  de- 
pend or  with  wnich  it  may  be  confounded  will  be  con- 
sidered in  another  place.  See,  also,  p.  18  et  seq. 

APHONIA  may  be  due  to  nervous  disorder,  as  hyste- 
ria or  hypochondria  ;  or  it  may  evidence  organic  lesion 


84 

of  the  nervous  centre ;  or  local  paralysis  from  loca 
causes  only;  a  turgid  state  of  the  laryngeal  surfaces; 
or  ulceration,  or,  in  old  age,  ossification  of  the  carti- 
lages. It  is  an  occasional  result  of  rheumatism,  and 
in  some  instances  arises  from  the  pressure  of  a  dilated 
or  aneurismal  aorta  or  other  tumor. 

When  present  it  must  be  demonstrated  to  depend 
on  the  trivial  and  transitory,  and  not  upon  the  graver 
causes.  Its  intimate  relation  with  tubercular  phthisis 
and  syphilis  renders  it  deserving  of  analysis. 

CONGESTION. — It  occasionally  occurs,  on  percussion, 
that  there  is  evident  diminution  of  the  normal 
resonance,  with  deficient  respiratory  sound  on  auscul- 
tation, at  the  same  time,  the  pitch  is  slightly  elevated. 
The  ratio  of  inspiration  to  expiration  may  be  unchanged 
— the  movements  slightly  augmented  in  frequency,  and 
a  trifle  more  of  muscular  effort  observable,  without 
marked  dyspnoea  being  present.  With  the  feeble  res- 
piration there  may  sometimes  be  noticed  a  <c  dryish, 
rather  fine,  but  distinctly  bubbling  rhonchus." 

This  condition  may  be  only  temporary  or  be  perma- 
nent in  its  character,  as  dependent  on  its  cause.  It  is 
important  to  diagnose  it  from  tuberculous  or  other 
deposits.  It  is  the  result  of  congestion,  and,  possibly, 
also  slight  pulmonary  oedema.  It  demands  research 
for  the  obstruction. 

It  is  capable  of  being  brought  on,  temporarily,  by 
the  ordinary  viscissitudes  of  temperature  and  humidity, 
"functional"  diseases  of  the  heart,  liver,  nervous 
apparatus,  &c. ;  or,  by  special  influences — malaria,  gase- 
ous or  atomic  emanations,  retained  excreta  and  the  like. 


But  it  is  also  often  the  result  of  more  or  less  perma- 
nent obstruction  in  the  pulmonary  blood-vessels,  or, 
again,  the  heart.  When  present  it  should  postpone 
decision  unti\  after  a  subsequent  examination.  Or 
else,  if  the  organic  origin  be  determined,  cause  immedi- 
ate rejection.  But  it  is  due  the  applicant  not  to  con- 
found it  with  the  result  of  tuberculous  deposit,  or  other 
grave  disease. 

DYSPNOEA — depends  upon  such  a  variety  of  causes 
that  it  is  not  diagnostic,  alone,  of  any  single  disease. 
When  considerable  and  permanent  it  should  reject, 
whatever  the  apparent  cause.  It  may,  however,  be  but 
a  peculiarity  of  a  nervous  temperament,  or  originated 
only  occasionally  by  peculiar  influences  depending  on 
idiosyncrasy. 

If  caused  by  permanent  obstruction  to  the  dia- 
phragmatic movements,  or  by  disease  of  the  larynx, 
trachea,  lung  tissue,  pleura  or  heart — it  must  reject,  at 
least  while  present.  It  is  well  to  recollect,  that  it  is 
rarely  a  concomitant  of  tuberculous  deposit ;  hence, 
the  popular  notion  that  phthisis  and  "asthma"  are 
incompatible. 

DEPOSITS — may  be  of  great  variety.  Prominently 
may  be  noticed:  the  Inflammatory  ^  Tuberculous^  Cancerous , 
Melanoid,  Typhoid,  and  Syphilitic.  The  first  two  only 
claim  particular  notice  in  this  place,  as  any  peculiarities 
about  the  latter  four  will  be  found  to  depend  on  the  dia- 
thesis or  cachexia  by  which  they  are  to  be  determined. 

The  results  of  Inflammatory  deposit  in  the  parenchyma 
are  traceable  from  historical  and  present  symptoms,  and 
the  physical  signs. 


86 

The  consolidated  exudate  of  acute  pneumonia  mav 
remain  unabsorbed  a  long  time,  or  even  permanently 
after  the  individual  has  regained  apparent  health. 
Contracting,  as  does  all  inflammatory  exudate,  the 
side  of  the  chest  overlying  may  flatten  as  after  pleurisy. 
There  is  less  range  of  costal  motion  resulting  (p.  71). 
It  is  dull  on  percussion,  with  bronchial  respiration  and 
broncophony  over  the  affected  part  of  the  lobe — not 
even  feeble  respiration  being  heard  as  after  pleurisy. 
Occasionally  around  the  part  there  is  uneven,  feeble 
respiration,  but  this  is  rather  significant  of  cedema  of 
the  parenchyma,  as,  otherwise,  it  will  be  found  harsher 
or  puerile.  Combined  with  these  signs  it  will  be  found, 
on  cautious  inquiry,  that  there  are  dyspepsia  and 
irregular  febrile  accessions — none  of  which  may  be  of 
sufficient  seventy  to  attract  attention  unless  sought  for. 

This  deposit  temporarily  postpones  —  but  its  diag- 
nosis from  tuberculous  deposit  should  be  made  out,  if 
possible,  to  give  opportunity  for  subsequent  examina- 
tion— as  well  as  in  case  of  cure  to  protect  the  Examiner's 
own  reputation.  All  the  evidences  of  the  tuberculous 
diathesis  must  be  explored ;  for,  even  when  the  phy- 
sical signs  presented  are  not  about  the  apices,  it  is  well 
to  bear  in  mind  that  there  may  occur  tuberculous  degen- 
eration of  the  exudate.  Where  it  involves  the  apices, 
the  diathesis,  hereditary,  or  acquired,  affords  our  only 
means  of  judging  of  the  abnormal  material  present. 

The  Life  Insurance  Examiner  is  not  called  upon  by 
Companies  to  investigate  well  marked  cases  of  'Tuber- 
culous Deposit,  accompanied  with  its  well  known 
rational  symptoms.  He  is  to  watch  for  its  incipiency 


with  the  extremes:  anxiety,  for  it  is  known  to  be 
the  greatest  possible  source  of  their  financial  losses. 
Qbsta  principiis  is,  most  emphatically,  to  be  his  motto. 
By  his  exercise  of  care,  skill  and  sagacity  he  will  be 
enabled  to  reduce  those  losses  to  a  minimum  unexpected 
before  the  introduction  of  Physical  Diagnosis. 

It  is  proper  to  remark,  that  when  the  physical  signs 
give  evidence  of  deposit  about  the  superior  lobes  of 
the  lungs  it  must  reject,  whatever  the  apparent  diathe- 
sis. It  is  equally  important  to  remember  that  the  dia- 
thesis may  be  strongly  marked — to  such  an  extent, 
indeed  as  to  determine  rejection,  when  none  of  the 
usual  signs  of  deposit  are  discoverable.  In  the  vast 
majority  of  cases,  the  two  are  associated  long  before 
manifestation  of  any  of  the  characteristic  symptoms 
produced  by  the  process  of  softening. 

Perhaps  the  most  observable  early  sign  is  Prolonged 
Expiration;  then  Vesicular  Murmur  lessened  at  the  part 
— Puerile  around;  Inspiratory  Sound  less  forcible,  higher 
in  pitch,  and  Bronchial  Respiration  more  distinctly 
tubular;  Focal  Fremitus  exaggerated;  Dullness  more 
or  less  decided  on  Percussion  ;  a  little  later,  Flattening 
with  less  superior  costal  motion  and  more  diaphrag- 
matic— the  shoulders  being  more  perceptibly  elevated 
at  each  inspiration,  whilst  the  general  frequency  of  the 
movements  is  accelerated  to  24  or  28  in  the  minute,  or 
even  beyond  thre  on  the  slightest  excitement. 

Owing,  probably,  to  their  usually  more  quiescent 
state,  the  apices  of  the  lungs  are  most  liable  to  the 
deposit,  but  other  causes  enforcing  similar  quiescence 


88 

of  any  part  of  the  parenchyma  may  determine  its  loca- 
tion in  that  part.     The  supra  scapular,  supra,  and  infra 
clavicular  regions,  in  the  absence  of  historical  symp 
toms  pointing  elsewhere,  are   the  parts  first  to   come 
under  investigation. 

In  these  regions  percussion  sound  elicited  may  be 
deficient  in  clearness  and  in  duration,  with  lessened 
elasticity,  and  even  when  the  deposit  is  small  and  in 
scattered  points,  there  will  be  less  increase  in  reson- 
ance over  the  affected  than  the  sound  part,  when  the 
lung  is  inflated  by  full  inspiration — the  dullness  more 
pronounced  at  the  end  of  a  complete  expiration. 

By  auscultation  the  vesicular  sounds  may  be  found 
varied  within  a  limited  space — suppressed,  weak  or 
exaggerated.  The  displaced  tubular  sound  elevated  in 
pitch,  harsher  and  prolonged.  Crepitant  dry  rales, 
or,  later,  of  a  moist  character.  More  or  less  distinct 
broncophony,  and  the  sounds  of  the  heart  heard  with 
unusual  distinctness  through  the  changed  conducting 
medium.  The  rhythm,  as  previously  noted,  is  liable 
to  irregularity. 

The  physical  signs  thus  briefly  alluded  to  determine 
the  presence  of  an  abnormal  deposit  more  or  less 
extensive,  according  to  their  distinctness  of  manifesta- 
tion, and,  even  in  the  absence  of  the  so-calledcrational 
symptoms'  of  incipient  Phthisis,  preclude  insurance — 
unqualifiedly. 

Not  all  of  them  may  be  present,  and  doubt  may 
arise,  to  be  decided  perhaps  by  reference  to  the  his- 
tory and  diathesis  of  the  applicant.  If  these  are  un- 
satisfactory, the  company  must  have  the  benefit  of  the 


89 

doubt  and  the  party  be  declined.      (Vid.  DIATHESIS.) 

The  Typhoid  Deposit  is  noticeable  for  the  reason  that 
whereas  it  will  yield  the  same  physical  signs  as  the 
true  tubercular,  and  is  prone  to  produce  similar 
results  by  its  softening,  nevertheless  it  is  capable  often 
of  being  permanently. removed,  and  perfect  local  and 
constitutional  health  be  restored ;  so  that  the  case 
once  properly  rejected  by  an  experienced  examiner 
may,  ultimately,  be  accepted  by  one  equally  as  cautious 
and  expert.- 

The  same  remark  may  be  made  with  regard  to  the 
Syphilitic  Deposit.  The  "gummata'  will  yield  the  same 
physical  signs  as  tubercle,  but  eventually,  under  appro- 
priate treatment,  disappear.  But  while  present  they 
reject — as  must  the  cachexia  upon  which  they  depend. 

The  Cancerous  and  Melanoid  Deposits  likewise  ex- 
clude, because  of  the  physical  signs  afforded,  as  well 
as  the  cachexiae  originating  them. 

EMPHYSEMA.  —  The  pathological  and  prognostic 
importance  of  this  lesion  depends  wholly  upon  its 
causation.  Unless  very  extensive  it  may  not  be  said 
to  shorten  life,  yet,  like  a  contracted  chest  and  small 
lungs,  it  lessens  vital  capacity  for  aerating  the  blood 
under  circumstances  demanding  an  increase  of  the 
usual  energy  of  the  process,  and  thus  renders  its  sub- 
ject an  easier  prey  to  intercurrent  diseases.  A  local 
Emphysematous  condition  is  not  infrequently  associ- 
ated with  tubercular  lesion,  but  ordinarily  its  presence 
over  any  considerable  portion  of  the  parenchyma  is 
said  to  lessen  the  liability  to  tubercle,  haemoptysis  and 
pneumonia.  Hypertrophous  Emphysema  is  a  nearly 


90 

incurable  affection — the  Atrophous  or  Senile  form 
absolutely  so.  Both  varieties  tend  to  produce  enlarge- 
ment of  the  heart.  The  hypertrophous  form  is  usu- 
ally associated  with  and  probably  caused  by  bronchitis, 
which  therefore  should  be  looked  for.  It  may  be 
hereditary,  and  in  its  manifestation  is  confined  to  no 
age,  sex,  or  condition.  The  atrophous  form  is  con- 
fined mainly  to  those  well  advanced  in  years.  In  the 
first  form  the  chest  is  locally  or  generally  enlarged,  so 
as  to  give  a  bulging  appearance,  very  peculiar  in  char- 
acter when  considerable  in  extent.  The  spine  curves 
anteriorly,  and  the  angle  of  junction  with  the  ribs 
becomes  more  obtuse. 

Percussion  gives  increased  resonance,  sometimes  of 
drum-like  intensity,  but  with  lesssened  resistance  of 
the  thoracic  parietes.  Auscultation  shows  feeble  res- 
piration in  the  affected  parts  with,  it  may  be,  puerile 
or  harsh  vesicular  murmur  in  the  healthy  structure. 
Associated  with  these  are  usually  found  the  abnormal 
sounds  of  bronchitis  or  asthma.  The  rhythm  of  the 
inspiratory  movements  is  likely  to  be  irregular,  and 
expiration  prolonged. 

There  is  dyspnoea  continually,  and  this,  at  times, 
deepens  into  the  asthmatic  paroxysm.  The  superficial 
veins  are  turgescent,  and  the  hue  of  the  skin  is  darkened 
by  the  imperfectly  aerated  blood.  The  features  wear 
the  characteristic  marks  of  habitual  laborious  breath- 
ing. With  exception  of  the  general  expansion  and 
bulging  of  the  chest,  the  atrophous  variety  presents  a 
similar  array  of  signs  and  symptoms.  The  existence 


91 

of   either  form  of  the   lesion   being   established,   the 
applicant  must  be  rejected. 

EMPY^EMIA  is  usually  made  out  with  sufficient  accu- 
racy by  the  historic  and  present  symptoms,  and  the 
physical  signs  of  pleuritic  effusion.  It  of  course  rejects. 
It  may  be  borne  in  mind  that  occasionally  a  fistulous 
opening  occurs,  and  the  contentsof  the  pleural  cavity 
are  discharged  a  long  distance  from  it.  Such  cases, 
mth  tolerably  fair  health,  have  been  mistaken  for 
fistulae  or  ulcers  from  other  causes.  The  previous 
occurrence  of  pleurisy  and  the  presence  of  a  supposed 
"fever  sore0  on  the  back  or  elsewhere  that  pus  may 
find  its  way,  demands  caution. 

HEMOPTYSIS  has  been  referred  to  (p.  34). 

HEMATEMESIS. — (Vid.  p.  35.) 

HYDROTHORAX  —  although  the  party  may  appear 
otherwise  in  perfect  health,  while  present  postpones, 
whatever  the  cause.  If  connected  with  structural  lesion 
of  the  heart,  liver  or  kidneys,  it  positively  declines. 

PNEUMOTHORAX  rejects  as  decidedly  as  Emphysema, 
and  hence  its  differential  diagnosis  from  the  latter  is 
unnecessary. 

PLEURODYNIA,  being  but  a  mere  symptom,  requires 
analysis.  The  term  is  carelessly  applied  to  cases 
which  may  prove  to  be  rheumatism  of  the  intercostal 
muscles;  intercostal  neuralgia,  the  chest  pains  of 
phthisis,  or  chronic  pleurisy,  or  from  carcinoma 
within  the  parietes.  It  is  properly  restricted  to  the 
first  mentioned  disorder.  The  pain  on  movement  is 
likely  to  locally  diminish  the  expansion  of  the  parietes, 
and  hence  there  will  be  less  distinct  respiratory  mur- 


92 

mur,  and  less  resonance  on  percussion.  The  remark- 
able aggravation  of  pain  by  movement,  ibsence  of 
other  physical  signs  of  deposit,  &c.,  and  reference  to 
the  diathesis,  will  be  sufficient  to  diagnose  the  case. 

Tntercostal  neuralgia  is  distinguishable  by  the  ab- 
sence of  abnormal  physical  signs — by  its  tendency  to 
paroxysmal  or  periodical  forms,  and  by  the  diathesis 
present.  Its  obstinate  continuance  may  point  to 
spinal  lesion,  or  that  of  remote  organs  with  which  the 
part  affected  is  in  relation  through  reflex  nervous 
action.  Movements  aggravate  it  very  little  if  at  all. 
Neither  the  simple  rheumatic  or  neuralgic  affection 
rejects,  unless  connected  with  evidence  of  constitu- 
tional or  organic  disease. 

The  chest  pains   of  phthisis,  chronic  pleurisy,  car- 
cinoma,  &c.,    need  only  be  mentioned  to  direct   the 
attention  of  the  examiner  to  their  differential  diagnosis 
Of  course  each  rejects. 

TUMORS,  within  the  thoracic  cavities,  whatever  their 
nature,  may  attain  considerable  size  before  producing 
noticeable  symptoms.  Eventually  their  pressure  upon 
the  lungs  or  heart,  the  nerves  or  blood-vessels  may 
give  rise  to  pain,  dyspnoea,  palpitation,  dysphagia,  dis- 
placement of  organs,  interference  with  the  circulation, 
haemoptysis,  inflammation  with  its  results,  bulging  of 
the  ribs  and  sternum,  &c.  But  where  these  symptoms 
are  present  parties  rarely  present  themselves  for  exam- 
ination, or  if  they  do,  the  matter  is  easily  disposed  of. 

According  to  their  location  they  will  change  the 
normal  auscultatory  and  percussion  sounds.  Dimin- 
ished resonance  and  feeble  vesicular  murmur  are  the 


93 

necessary  physical  signs.  Light  percussion  may  show 
resonance,  whilst  a  stronger  blow  will  elicit  deep- 
seated  dullness.  The  particular  character  of  the 
tumor  can  only  be  surmised  from  concurrent  symp- 
toms, and  the  diathesis  or  cachexia  present.  The  most 
satisfactory  diagnosis  is  here  the  result  of  the  exclusive 
metnod  —  determining  the  absence  of  other  lesions 
which  might  account  for  the  signs  and  symptoms. 

The  intra-thoracic  tumor,  whether  aneurismal,  can- 
cerous, fibrous,  fatty,  steatomatous,  or  whatever  it 
may  occur,  positively  forbids  assurance. 

In  passing  from  the  consideration  of  the  respiratory 
organs,  it  is  not  out  of  place  to  remark  that,  the  whole 
thorax  should  be  comprehended  at  a  coup  dy  ceil,  and 
yet  individual  parts  be  thoroughly  scanned.  The 
unassisted  ear,  applied  to  the  chest,  will  often  gain  a 
more  satisfactory  acquaintance  with  its  general  con- 
dition and  vital  capacity,  than  can  be  gained  by  the 
most  expert  use  of  the  stethoscope.  Whether  the 
ear  is  applied  directly  to  the  chest,  or  a  stethoscope  is 
interposed,  is  not  a  matter  of  so  much  importance 
as  that  the  examiner  be  able  to  hear  with  the  ear,  and 
correctly  interpret  the  report  of  the  organ. 

IV. 

Heart  and  Circulatory  System, — The  remark  on 

page  21  may  be  repeated:  CeOrganic  disease  of  the  heart 
positively  excludes."  Its  acute  affection  or  chronic 
lesion  with  marked  rational  symptoms  will  not,  mani- 
festly, be  brought  to  the  Insurance  Examiner's  atten- 


94 

tion ;  but  as  its  lesions,  even  when  giving  rise  to  no 
inconvenience  of  which  the  party  himself  may  be  con- 
scious, nevertheless  are  liable  suddenly  or  slowly  to 
cut  short  the  life,  it  becomes  absolutely  essential 
to  explore  the  slightest  deviation  from  its  normal 
condition. 

^LOCATION. — Recognized  by  its  impulse,  palpitation 
and  percussion,  the  heart  should  occupy  in  relation  to 
the  thoracic  wall  a  space  about  two  inches  in  diameter 
vertically  between  the  fourth  and  sixth  ribs,  and  trans- 
versely a  little  to  the  left  of  the  sternum — the  impulse 
of  the  apex  being  about  two  inches  below  the  nipple, 
and,  varying  with  the  size  of  the  chest,  an  inch  towards 
the  mesial  line, 

Any  change  from  this  location  requires  inquiry  as 
to  its  cause.  Prominently  among  causes  are  to  be 
mentioned ;  Pleuritic  Effusions,  whether  of  serum, 
pus,  or  air ;  Emphysema ;  Deposits  in  the  Lung, 
whether  tubercular,  inflammatory,  cancerous  or  other ; 
Tumors ;  Dilatation  of  the  Stomach,  Enlargement 
of  Liver,  Ascites,  &c. 

BULGING  OR  DEPRESSION. — Protruding  of  the  prae- 
cordial  region  indicative  of  Hydro-pericardium,  or 
Hypertrophy  of  the  organ.  Depression,  if  consider- 
able, indicative  of  previous  Pericarditis  with  its 
contracted  exudates  and  adhesions. 

IMPULSE. — This  is,  as  might  be  expected,  normally 
stronger  in  persons  of  a  lean  habit  than  in  the  corpu- 
lent. Its  location  is  changed  by  position,  whether 
erect  or  supine ;  by  distension  of  the  stomach ;  oy 
respiratory  movements,  &c.  It  is  augmented  ir 


95 

extent  and  intensity  by  hypertrophy.  It  is  augmented 
in  area  of  vibration,  but  diminished  in  intensity  by 
dilatation  or  pericardial  effusion,  or  fatty  degenera- 
tion. A  feeble  impulse,  irrespective  of  local  lesion 
of  the  heart  itself,  may  indicate  cerebral  disease,  im- 
poverished or  morbid  blood,  or  reflex  influences  of 
depression  from  disease  of  remote  organs. 

A  broken  or  irregular  impulse  is  suggestive  of  peri- 
cardial adhesions.  When  both  a  systolic  and  diastolic 
impulse  are  felt,  hypertrophy  with  dilated  ventricles 
is  to  be  looked  for.  In  connection  with  the  impulse 
may  be  noticed  the  purring  thrill  of  Laennec,  suggest- 
ing possible  presence  of  valvular  stiffening.  Vibration 
as  of  friction  may  be  felt  from  roughened  pericardial 
surfaces. 

AREA  OF  DULLNESS. — The  diameter  indicating  the 
approximation  of  the  heart  to  the  parietes  of  the 
chest  may  be  extended  by  strong  percussion,  eliciting 
deep-seated  dullness  over  the  entire  heart  and  large 
blood-vessels  superior.  But  if  without  change  in  the 
strength  of  stroke,  the  area  is  materially  increased, 
there  is  room  for  apprehension  of  fluid  effusions  in 
the  pericardium  or  enlargement  of  the  heart  itself.  Of 
course,  local  pleuritic  effusion  may  be  confounded  with 
it,  but  to  the  examiner  this  is  of  little  consequence, 
as  either  must  reject,  or,  at  best,  postpone.  The  same 
remark  may  be  made  as  to  the  differential  diagnosis 
of  Hydro-pericardium,  and  Concentric  or  Eccentric 
Enlargement  of  the  Heart. 

An  apparent  diminution  of  the  area  of  dullness  is 
noticeable  during  a  deep  respiration,  but  if  very 


96 

considerable,  or  there  is  abnormal  resonance,  there 
may  be  pulmonary  emphysema,  or  hydroeria,  either  of 
which  reject.  In  doubtful  cases  the  applicant  should 
be  examined  both  in  the  erect  and  recumbent  position. 
Abnormal  dullness  in  the  aortic  region  calls  attention 
to  the  possibility  of  dilatation,  or  aneurism  of  the 
the  great  arterial  trunk. 

PULSATIONS. — In  addition  to  the  character  of  the 
impulse  produced  by  the  cardiac  movements,  it  be- 
comes necessary  to  note  the  rhythm,  which  may  be 
varied  in  frequency,  order  of  succession,  and  multiple 
character.  Coincidently,  with  the  pulse  (p.  64  et.  seq.} 
it  may  be  increased  or  diminished  in  frequency,  or  it 
may  become  irregular  or  intermittent.  Its  normal 
range  for  insurance  purposes  is  from  sixty  to  eighty- 
five,  or  possibly  ninety  in  the  minute.  Continuously 
above  or  below  this  standard  should  reject  or  post- 
pone. But  the  great  power  of  the  nervous  system 
over  the  contractions  should  be  kept  in  mind.  Mental 
excitement  under  the  examination,  in  nervous  sub- 
jects, will  often  throw  the  beats  up  to  a  hundred  or 
more.  If  without  this  the  applicant  stands  erect,  and 
brings  the  muscles  of  the  extremities  into  a  state  of 
contraction,  voluntarily  or  involuntarily,  the  beats 
will  readily  pass  the  hundred.  Hence  the  necessity 
of  waiting  examination  until  the  effects  of  exercise  or 
mental  excitement  have  passed,  and  then,  while  the 
person  is  in  the  sitting  or  recumbent  position,  enjoin- 
ing upon  him  as  complete  relaxation  of  all  the  muscles 
as  possible.  With  due  precautions,  if  there  be  not 
some  fixed  cause  of  a  morbid  character,  apparent 


97 

abnormalities  in  frequency  may  be  made  to  disappear, 
Extreme  rapidity  or  palpitation  (p.  28,)  although 
generally  accompanying  some  lesion  of  the  heart, 
cf  Hears  no  positive  relation  to  any  special  cardiac 
malady,  and  is  therefore  not  diagnostic  of  any."  The 
symptom  directs  attention  to  possible  cardiac  lesion, 
but  in  the  vast  majority  of  instances  to  dyspepsia, 
impaired  blood,  or  nervous  disorder.  Retardation 
of  the  pulsation  points  to  some  affection  of  the 
nervous  centre,  or  degeneration  of  the  cardiac  paren- 
chyma, or  alteration  of  the  aortic  orifice.  Irregularity 
of  contraction  is  of  rather  more  significance,  as  indi- 
cating valvular  or  parenchymatous  local  change,  or 
grave  lesion  of  the  nervous  centres  or  remote  organs. 
Yet  many  cases  occur  where  irregularity  is  the  rule 
even  during  most  perfect  health.  Hence,  taken  alone, 
it  ought  not  to  cause  rejection.  Palpitation  with 
irregularity  and  deficient  impulse  suggests  dilatation 
and  weakened  walls,  although  other  physical  signs 
may  be  wanting.  In  this  case  the  rational  symptoms, 
age,  habits,  condition  of  the  digestive  system,  the 
blood,  &c.,  will  afford  sufficient  concurrent  evidences 
to  decide  upon  the  real  character  of  the  case. 

The  intermittent  pulsation  may  be  an  individual 
peculiarity  in  health,  but  generally  indicates  organic 
cardiac  lesion,  or  some  cause  either  temporarily  or 
permanently  impressing  the  nervous  system.  It  is 
of  graver  character,  on  the  whole,  than  either  changes 
in  frequency  or  regularity. 

The  relation  of  the  systolic  and  diastolic  sounds  to 
^he  intervals   of    rest    may   be  varied;    more   usually 
7 


98 

the  longest  interval  is  prolonged,  which  may  depena 
on  auriculo-ventricular  stricture  ;  or,  again,  the  first 
sound  may  be  prolonged  over  upon  the  second,  sug- 
gesting (C  hypertrophy  with  stricture  of  the  arterial 
orifices."  In  strongly  marked  cases  of  this  kind  the 
diastolic  sound  is  sometimes  wholly  suppressed. 

On  the  other  hand,  there  may  be  heard  three  or 
four  sounds  instead  of  two,  ascribable  to  important 
organic  changes  in  the  structure.  The  precise  nature 
of  these  changes  it  is  unnecessary  to  point  out,  as  this 
abnormality  must  peremptorily  exclude  from  assurance, 
whatever  its  plausible  explanation. 

CHARACTER  OF  SOUNDS. — The  "dull,  booming  ana 
prolonged"  first  sound  of  the  heart,  and  the  cc  short, 
abrupt  and  clear"  second  sound,  in  a  condition  of 
health  are  sufficiently  distinct  to  be  easily  recognized, 
and  when  present  for  any  even  short  period  argue  a 
healthy  organ,  but  variation  of  these  sounds  may  arise 
from  incidental  causes  not  implicating  the  structure. 
The  healthy  sounds  when  heard  demonstrate — abnor- 
mal sounds  throw  doubt,  and  their  cause  must  be 
cleared  up. 

Increased  intensity  of  the  sounds  may  depend 
on  hypertrophy  with  dilatation,  induration  of  the 
muscular  tissue  from  carditis,  or  merely  upon  nervous 
excitability.  They  may  derive  increased  loudness 
from  solid  or  fluid  deposits,  in  which  case  they  are 
heard  with  distinctness  at  distant  parts  of  the  chest. 

Feebleness  of  the  sound  may  indicate  fatty  degene- 
ration, or  softening,  atrophy,  general  debility,  or 
accumulation  of  fluid  in  the  pericardium  ;  or,  again, 


99 

the  interposition  of  the  non-conducting  emphysematous 
lung. 

Increased  sharpness  may  suggest  thinness  of  the 
walls  of  the  heart,  as  dullness  points  to  hypertrophy 
and  thickened  valves. 

A  dry  and  sharp  sound  —  increased  tensity  of  the 
valves.  Hoarse  and  muffled — a  tumid  condition  of  the 
same. 

Metallic  sound  is  usually  dependent  on  gastric 
flatulency  or  nervous  excitement,  but  sometimes  due 
to  stiffening  of  the  muscular  structure  from  old 
carditis. 

The  addition  of  a  bruit  to  sounds  is  a  circumstance 
which  demands  all  the  skill  of  the  Examiner  to  appreci- 
ate in  its  bearings.  The  blowing  sound  may  vary 
from  the  lightest  murmur  to  the  grating,  rasping,  and 
even  whistling  or  musical  sound.  It  is  well  to  recol- 
lect that  the  intensity  of  the  abnormal  sound  is  not 
coincident  with  the  extent  of  the  lesion.  The  bruit 
de  soufflet  is  caused  by  some  obstruction  to  the  free 
flow  of  blood  through  the  heart  and  great  vessels,  or 
by  a  wrong  composition  of  the  blood,  or  nervous 
excitability.  In  the  latter  instances  the  bruit  is  often 
temporarily  absent,  but  in  case  of  organic  lesion,  the 
bellows-murmur,  of  greater  or  less  intensity,  must 
always  be  present. 

The  differential  diagnosis  of  the  immediate  causes 
of  the  changed  character  of  the  sounds  is  not  so  im- 
portant here,  for  when  traced  to  actual  organic  lesion 
of  the  heart,  the  case  must  be  rejected,  whatever  part 


too 

of  the  structure  is  involved.     But  for  convenience  of 
reference  Dr.  Henry's  diagnostic  table  is  introduced : 
BRUIT  :    If  systolic  and  loudest  at 

Base  =  AORTIC  obstruction. 
Apex  =  MITRAL  insufficiency. 
BRUIT  :    If  diastolic  and  loudest  at 

Ease  =  AORTIC  insufficiency. 
Apex  =  MITRAL  obstruction. 
PULSE  :      If   regular,     full,    or     strong,   jerking    or 

resilient  —  AORTIC  disease. 

PULSE  :      If  irregular,   intermittent,   unequal,    soft, 
small,  weak  =  MITRAL  disease. 

The  systolic  bruit,  synchronous  with  the  pulse  and 
most  audible  at  the  apex,  indicates  mitral  disease. 
The  diastolic  bruit,  most  audible  over  the  centre  of 
the  sternum  and  along  the  course  of  the  aorta,  is 
indicative  of  aortic  disease.  Blowing  sounds  from 
functional  disorder,  impaired  blood,  etc.,  are  usually 
soft  —  rarely  harsh  or  musical.  Although  there  is 
evidence  that  the  bruit  is  occasionally  an  individual 
congenital  peculiarity,  nevertheless  the  rarity  of  such 
cases,  and  the  difficulty  of  establishing  their  history, 
must  preclude  their  acceptance.  Recurrence  to  the 
historical  and  other  rational  symptoms,  may  convince 
that  the  abnormal  sound  does  not  depend  on  or- 
ganic change,  but  while  present  it  rejects  or  at  least 
postpones. 

LOCATION  OF  SOUNDS. —  Effusions,  tumors,  morbid 
adhesions,  etc.,  may  displace  the  sounds  laterally  or 
antero-posteriorly.  Descent  of  the  sounds  indicates 
hypertrophy  with  dilated  auricles,  or  tumors  at  the 
base  of  the  heart.  Abdominal  distension,  by  raising 
the  diaphragm,  may  cause  ascent  of  the  sounds. 


101 

Friction  sounds  are  indicative  of  changes  in  the  serous 
lining  of  the  pericardium,  analogous  to  those  which 
have  been  alluded  to  on  the  pleura,  tending  to  adhesions, 
contraction  and  impairment  of  cardiac  movements. 
When  present  they  reject. 

DISEASES. —  Among  those  affections  of  the  heart  to 
which  the  examiner's  attention  is  to  be  directed  may 
be  noted :  Aneurism,  Angina  Pectoris,  Adhesions, 
Atrophy,  Cyanosis,  Degeneration,  Dilatation,  Hyper- 
trophy, Malformations,  Myocarditis,  Pericarditis,  Val- 
vular changes,  and,  lastly,  disorders  not  involving  ap- 
parent structural  changes,  but  rendering  its  movements 
and  sounds  abnormal. 

Aneurism  may  affect  the  wall  of  the  heart,  or  the 
coronary  arteries.  Its  symptoms  and  signs  are  alike 
obscure,  but  the  possibility  of  a  party,  pronounced 
free  from  cardiac  disease,  dying  suddenly  from  this 
lesion  renders  it  desirable  for  the  examiner  to  bear  in 
mind  its  occasional  occurrence  —  particularly  when 
investigating  obscure  cases. 

Angina  Pectoris  —  that  intense  pain  in  the  praecor- 
dial  region,  with  suffocative  sensations  and  fearful 
anticipations  of  sudden  death  —  is  generally  indicative 
of  fatty  degeneration  or  obstruction  of  the  coronar) 
arteries.  In  all  cases  it  rejects. 

Adhesions,  impairing  the  mobility  of  the  organ,  and 
most  usually  accompanied  by  lingering  pericarditis, 
temporarily  rejects.  In  such  cases  there  is  possibility 
of  ultimate  recovery. 

Atrophy  —  diminished  area  of  dullness,  lessened 
intensity  of  sounds  and  impulse.  This  condition  is 


IO2 

invariably  connected  with  such  a  degree  of  general 
cachexia,  or  debility,  that  the  latter  alone  would 
preclude  the  risk. 

Cyanosis,  usually  congenital,  but  not  always — some- 
times appearing  late  in  life  —  is  both  incurable  and 
subjects  to  the  chances  of  sudden  death. 

Degeneration,  ordinarily  fatty  and  coincident  with 
similar  affection  of  the  kidneys,  liver,  etc.,  rejects.  It 
is  tolerably  recognizable  by  exclusive  diagnosis.  Feeble 
impulse,  weak  sounds,  slownesss  of  pulse,  occasionally 
dyspnoea  with  evidences  of  pulmonary  congestion, 
general  debility,  giddiness,  faintness,  nervous  exhaus- 
tion, etc.  In  all  cases  of  obesity,  especially  where 
fattening  has  taken  place  rapidly,  as  often  during  con- 
valescence from  low  fevers,  the  heart  must  be  carefully 
inspected  for  signs  of  this  grave  change. 

Dilatation  may  be  coincident  with  hypertrophy,  natu- 
ral thickness  of  the  wall,  or  with  the  latter  attenuated. 
In  the  last  mentioned  form  there  are  increased  area  of 
dullness,  less  powerful  impulse,  but  increased  intensity 
of  sounds.  The  pulse  is  weak  and  irregular.  Inac- 
tive capillary  circulation  in  the  extremities.  Gastric 
and  cerebro-nervous  symptoms,  dyspnoea,  palpitation, 
etc.  However  mild  the  rational  symptoms,  the 
dilatation  alone,  if  made  out,  rejects. 

Hypertrophy^  whether  concentric  or  eccentric^  declines 
the  risk.  It  is  usually  connected  with  valvular  ob- 
struction, although  hypertrophy  of  the  right  ventricle 
may  depend  on  obstruction  to  the  pulmonary  circula- 
tion. Differential  diagnosis  is  scarcely  important  here. 
Increased  area  of  dullness,  augmented  impulse,  less 


distinctness  of  systolic  sound,  and,  usually,  concurrent  _ 
changes  in  the  valvular  sounds.  Full  and  flushed  face, 
headache,  vertigo,  cardiac  uneasiness,  pain  or  palpita- 
tion increased  by  exercise,  dyspnoea,  etc.,  may  be 
acknowledged  as  present  to  a  greater  or  less  extent. 
The  hypertrophy  is  rather  the  result  of  disease  than  a 
disease  itself/ but  it  is  so  fraught  with  danger  that  the 
applicant  must  be  turned  over  to  invalid  companies. 

Malformations  and  misplacements  of  the  heart  scarcely 
need  more  than  an  allusion  in  this  place.  Cyanosis, 
dyspnoea,  palpitation  and  morbid  sounds  may  be  pres- 
ent. The  malformed  heart  always  vitiates  the  risk, 
even  though  signs  of  its  injurious  result  be  not  dis- 
coverable. Congenital  misplacement  of  the  heart  is 
so  rare  a  phenomenon  that,  practically,  it  may  be  ig- 
nored. But  if  displaced  by  effusions,  tumors,  etc., 
the  cause  will  be  warrant  for  rejection. 

Myocarditis  is  of  importance  to  the  examiner  from 
its  results,  especially  softening  and  induration.  The 
latter  may  ultimate  in  a  dense  cartilaginous  transfor- 
mation of  the  tissue,  or  even  osseous  deposits.  Evi- 
dences of  either  of  these  conditions  utterly  preclude 
acceptance  of  the  applicant.  (Vid.  p.  21.) 

Pericarditis  often  leaves  behind  it  adhesions  impair- 
ing the  cardiac  movements,  or  effusions  impeding  dila- 
tation. The  methods  of  diagnosis  have  been  pre- 
viously given.  Entire  absence  of  rational  symptoms, 
and  physical  signs  of  lesion,  must  be  insisted  upon 
prior  to  insurance.  Repeated  attacks  disqualify, 
whether  any  symptoms  or  signs  of  mischief  are  present 
or  not. 


IO4 

Valvular  changes,  aside  from  their  interference  with 
the  transit  of  blood  through  the  heart,  are  significant 
of  chronic  Endocarditis,  Bright's  disease,  Rheuma- 
tism, Gout,  and  various  constitutional  derangements 
of  the  system  with  impaired  nutrition.  So  constant 
is  this  association  that,  when  there  is  doubt  as  to  the 
meaning  of  abnormal  valvular  sounds,  judgement  can 
usually  be  largely  aided  by  careful  attention  to  the 
rational  evidences  of  these,  to  the  superficial  observer, 
apparently  disconnected  difficulties. 

Aside  from  the  cachexia  determining  valvular  change, 
all  forms  are  characterized  by  symptoms  denoting  in- 
terference with  the  capillary  circulation.  Hence  the 
increased  frequency  of  respiration,  and  the  dysp  -» 
or  rather  the  peculiar  breathlessness,  under  all  tnose 
influences  which  tend  to  render  the  pulse  more  rapid. 
Even  when  there  are  few  other  noticeable  symptoms, 
it  will  be  found,  on  questioning,  that  the  party  sleeps 
at  night  with  the  head  and  shoulders  unusually  ele- 
vated. There  will  be  evidence  of  oppressed  respiration 
without  actual  dyspnoea,  with  semi-voluntary,  deeper 
inspirations  at  short  intervals.  The  movements  are 
languid  and  the  extremities,  in  the  evening  particu- 
larly, are  apt  to  be  puffy  and  swollen.  A  short,  dry 
cough,  palpitation,  occasional  headache,  restless  and 
disturbed  sleep,  and  praecordial  pains  are  often  present, 
and  usually  attributed  to  dyspepsia  by  the  patient. 
Hepatic  venous  changes  and  disturbed  action  of  the 
kidneys  are  the  almost  natural  sequences,  and  without 
due  consideration  there  is  a  liability  to  refer  all  the 
unpleasant  feelings  of  the  individual  to  "  functional " 


disturbances  of  these  organs.  In  all  doubtful  cases, 
an  investigation  of  the  condition  of  the  renal  organs 
will  throw  much  light  on  the  diagnosis. 

With  the  later  symptoms  and  results  of  the  valvular 
lesion  the  Insurance  Examiner,  as  such,  has  nothing 
to  do,  but  a  few  words  with  regard  to  the  relative  fre- 
quency of  the  varieties,  and  their  comparative  fatality, 
may  not  be  considered  out  of  place. 

Aortic  Obstruction  is  one  of  the  most  frequent  re- 
sults of  chronic  valvular  disease,  and  is  longer  in  pro- 
ducing fatal  results.  It  involves  slow  dilatation  of 
the  left  ventricle  and  thus  renders  the  mitral  valves 
insufficient,  the  consequence  of  which  is  mitral  regur- 
gitation,  with  symptoms  of  congestion  of  the  lungs. 
In  this  obstruction  there  is,  when  the  heart  is  beating 
forcibly,  marked  parietal  vibration  over  the  base  of 
the  heart  and  the  aorta. 

Aortic  Regurgitation  is  also   quite  common,   an,.   „ 
fects   similarly    the  ventricle  and  mitral  valve.     The 
pulse  is  peculiar — "short  and  jerking/' 

Mitral  Obstruction  is  infrequent.  It  necessitates  dil- 
atation of  the  left  auricle  and  pulmonary  artery  with 
engorgment  of  the  lungs.  The  pulse  is  variable  in 
force,  but  rapid.  Cough,  respiratory  oppression,  and 
general  disorder  follow,  and  death  speedily  ensues, 
usually  from  pulmonary  oedema  or  apoplexy. 

Mitral  Regurgitation  is  the  most  easily  recognized  of 
all  the  valvular  lesions.  The  mitral  valve  seems  to  be 
the  favorite  point  of  attack  when. rheumatism  impli- 
cates the  heart.  The  systolic  murmur  is  manifested 
by  the  slightest  changes,  even  when  symptoms  are 


io6 

absent.  The  blood,  escaping  the  imperfectly  closed 
orifice,  is  driven  back  upon  the  lungs,  producing  con- 
gestion, with  feeble  pulse  and  dusky  comp.exion.  The 
left  side  of  the  heart  is  dilated — the  ventricle  also  be- 
ing hypertrophied.  There  is  a  chest  thrill,  but  it  is 
not  transmitted  along  the  aortic  trunk.  The  pulse  is 
irregular  and  deficient  in  fulness  and  force. 

Obstruction,  and  regurgitation,  through  the  pulmo- 
nary orifices  are  so  rare  as,  practically,  scarcely  to  de- 
mand notice.  Regurgitation  through  the  tricuspid, 
however,  may  not  infrequently  occur  as  a  consequence 
of  dilatation  of  the  right  ventricle,  which  then  be- 
comes hypertrophied,  the  auricle  and  vena  cava  dis- 
tended, and  there  is  a  strong  tendency  to  congestion  of 
the  systemic  and  cerebral  circulation. 

So  far  as  term  policies  are  concerned,  or  invalid 
risks,  simple  aortic  obstruction  is  by  far  the  most 
favorable  for  assurance.  Mitral  and  tricuspid  regurgi- 
tations  are  the  least  so.  A  system  otherwise  in  perfect 
order,  may  gradually  adapt  itself  to  the  changed  cardiac 
conditions,  and  life  be  prolonged  indefinitely. 

N ON- ORGANIC  DISEASES  of  the  heart  are  capable 
alone  of  producing  death,  and  hence,  on  determining 
the  absence  of  organic  lesion,  they  should  not  be  dis- 
missed unnoticed.  Youths  and  young  adults  are  lia- 
ble to  them  to  a  marked  extent.  So  also  women  about 
the  climacteric  period.  They  are  the  product  of 
nervous  exhaustion  or  oppression,  of  dyspepsia, 
gout  and  rheumatism.  Sexual  excesses,  uterine  irri- 
tation, over-use  of  narcotics  and  stimulants  etc.. 
readily  beget  them. 


io7 

Palpitation  and  intermittent,  irregular  and  feeble 
pulse  may  be  associated  with  valvular  murmurs,  closely 
simulating  those  from  organic  disease.  There  may  be 
praecordial  pains,  with  occasional  attacks  of  headache, 
giddiness,  or  even  syncope.  Violent  pulsations  of  the 
larger  arteries,  and  a  bruit  may  be  heard  along  their 
track.  There  may  even  be  subcutaneous  oedema. 

Dyspnoea  is  rarely  present,  and  at  times  the  valvu- 
lar sounds  are  healthy.  All  the  symptoms  are  more 
strongly  marked  than  in  real  organic  diseast.  Careful 
analysis  will  detect  differences  not  easily  described. 
The  concurrence  of  symptoms  will  develop  a  non-in- 
surable  condition,  at  least  temporarily  existent,  in 
doubtful  cases.  Diagnosis  from  fatty  degeneration 
will  give  the  most  difficulty.  Frequent  functional 
disorders  increase  the  liability  to  ultimate  organic 
diseases. 

Generally  the  blood  murmurs  of  non-organic  affection 
are  heard  at  the  base  of  the  heart,  but  occasionally, 
probably  rarely,  the  murmur  is  to  be  heard  over  the 
centre  of  the  heart,  -and  becomes  more  distinct  at  the 
apex.  In  the  latter  case  anaemia  is  usually  so  distinct 
as  alone  to  decline  the  risk. 

In  the  non-organic  affection  the  signs  of  hyper- 
trophy do  not  accompany  the  abnormal  bruit.  The 
murmur  is  heard  along  the  blood  vessels.  It  is  fol- 
lowed by  a  short  and  sharp  second  sound.  The  mur- 
mur is  almost  invariably,  notwithstanding  the  exag- 
geration of  other  symptoms,  of  a  soft  character. 

But  it  must  be  confessed  that  it  often  requires  the 
grestest  tact  to  decide  correctly  in  these  cases.  For 


108 

the  Insurance  Examiner  the  best  rule  is  to  examine 
at  different  times  and  with  the  most  rigid  precautions 
against  error,  recollecting  that  when  the  "functional" 
disorder  is  so  considerable  as  to  give  doubt  of  the 
presence  of  organic  change,  the  party  is  uninsurable 
on  that  account  alone. 

DISEASES  OF  BLOODVESSELS. —  The  occasional  occur- 
rence of  aneurism,  without  symptoms  noticed  by  the 
patient,  suggests  attention.  The  aorta  may  be  dilated, 
or  so  enlarged  by  aneurismal  tumor,  as  to  cause  bulg- 
ing of  the  thoracic  parietes  before  its  peculiar  and 
ultimately  terribly  distressing  effects  are  developed. 
Or  it  may  cause  what  is  supposed  to  be  laryngitis,  by 
pressure  on  the  recurrent  laryngeal  nerve ;  or  attacks 
of  dyspnoea,  analogous  to  paroxysmal  asthma.  When 
its  graver  influences  are  manifest,  naturally,  the  suf- 
ferer will  not  present  himself  for  assurance.  But 
earlier  examination  may  detect,  along  the  course  of  the 
aorta,  slight  protusion  and  dullness  over  the  surface. 
It  is  more  resistant,  and  the  systolic  impulse  is  com- 
municated strongly  to  the  finger.  There  may  be  vi- 
bration, but  this  is  not  always  present.  The  persis- 
tent systolic  impulse  at  the  point,  together  with  the 
usually  attendant  dyspnoea,  cough,  frequent  irregularity 
of  the  circulation,  swollen  veins  of  the  neck,  and  tho- 
rax;  sometimes  diversity  in  the  pulsations  of  the  two 
radial  arteries  from  pressure  on  the  sub-clavian;  con- 
traction of  a  single  pupil  on  the  affected  side,  with 
more  or  Jess  disturbance  of  remote  organs,  will  enable 
a  decisive  judgment  against  the  applicant.  x  When  evi- 
dences of  intra-thoracic  tumor  are  present,  differential 


109 

diagnosis  is  unnecessary,  for  any  kind  rejects,  but  it  is 
well  to  bear  in  mind  that  aneurismal  tumors  constitute 
the  largest  majority. 

The  condition  of  tne  arterial  system,  as  a  wholt, 
here  comes  under  review.  Is  there  an  aneurismal  ten- 
dency, from  disease  affecting  the  arterial  wall  ?  Does 
the  rigid  inelastic  artery  of  advanced  age  suggest  the 
conditions  of  senile  gangrene  ?  Is  the  structure  such 
as  to  endanger  rupture  and  apoplectic  extravasation 
in  the  brain  ?  Do  the  veins  show  marks  of  tardy  re- 
turn of  the  blood  ?  Has  the  valvular  structure  been 
obliterated  and  the  varicose  condition  ensued  ?  Ex- 
tensive varicosities  of  the  veins  impair  the  risk,  not 
solely  from  the  dangers  of  rupture  and  hemorrhage, 
but  because  indicative  of  either  a  general  tendency  to 
disease  of  the  venous  system,  or  some  obstruction 
which  may  be  of  permanent  character  on  the  proximal 
side  of  the  enlarged  vessel. 

Extraordinary  pulsatory  movements  of  the  arteries, 
as  noticed  particularly  along  the  aorta,  carotids  and  tem- 
porals, suggest  anaemia,  structural  derangement  of  the 
digestive  organs  as  in  the  gouty  diathesis,  or  great  ex- 
citability of  the  nervous  system.  In  the  female  it  is 
liable  to  be  associated  with  uterine  disease. 

In  some  instances  it  is  one  of  the  concurrent  evi- 
dences of  abuse  of  alcoholic  stimulants,  tobacco, 
opium,  etc. 

V. 

Abdominal  Organs,  — The  historical  indications 
may  call  attention  to  the  condition  of  particular  viscera, 


no 

but  in  every  case  the  general  contour  of  the  abdomen, 
its  proportion,  symmetry  and  movements  should  be 
observed.  It  is  proportionately  larger  in  children  than 
in  adults,  and  again  with  advancing  age  it  becomes 
more  protuberant.  Obesity  more  speedily  shows  it- 
self by  large  deposits  on  the  omentum  and  in  the  ab- 
domina'  walls.  It  may  be  distended  by  ascites,  by  ac- 
cumulated gases  or  by  tumors.  It  is  more  voluminous 
in  females  who  have  borne  children.  In  the  region  of 
the  epigastrium  it  is  always  enlarged  after  eating,  but 
in  many  cases  of  dyspepsia  it  may  become  enormously 
distended  by  persistent  flatulency. 
•  The  liver  or  spleen  may  be  so  increased  in  dimen- 
sions as  to  occupy,  respectively,  the  greater  part  of  the 
cavity.  Mesenteric  disease,  ovarian  growths,  encyst- 
ed fluid  or  solid  tumors,  accumulation  of  faeces  and 
hernial  protrusions,  severally,  may  change  its  outline 
and  indicate  more  or  less  grave  results. 

Retraction  of  the  walls  may  call  attention  to  general 
emaciation,  exhausting  chronic  diarrhoea  or  dysentery, 
metallic  poisoning,  tuberculosis  of  the  mesenteric 
glands,  or  occasionally  fibroid  or  cancerous  deposits  at 
the  orifices  of  the  stomach.  The  shrunken  abdomen 
warns  of  deficient  nutrition  and  cachexia.  It  is  also 
liable  to  be  present  in  organic  affections  of  the  brain. 

The  contour  and  proportion  are  best  observed  in 
the  erect  position,  but  if  circumstances  require  investi- 
gation of  the  exact  condition  of  the  viscera,  the  person 
should  be  placed  in  the  recumbent  position  with  the 
limbs  flexed  on  the  trunk.  With  proper  precautions 
to  relax  the  muscular  investment,  the  outline  and 


Ill 

genera,  condition  of  the  contained  organs  can  DC  ascer- 
tained with  very  great  exactness,  unless  the  party  is 
very  obese. 

THE  STOMACH,  if  abnormally  distended,  indicates 
impaired  digestion,  or  an  obstruction  to  the  passage 
of  the  chyme  from  its  cavity.  Deficient  secretion  of 
the  gastric  juice,  or  deficient  innervation  with  conse- 
quent loss  of  mobility,  are  suggested — the  deficient 
innervation  possibly  dependent  on  cerebral  lesion. 
Obstruction  involves  either  temporary  spasmodic  ac- 
tion^ or  a  thickened  or  carcinomatous  pylorus,  which 
latter  may  be  detected  by  deep  palpation. 

The  small  or  shrunken  stomach  accompanies  weak 
digestive  power  and  scanty  nutrition. 

THE  LIVER  enlarged,  points  to  endemic  influences 
and  portal  venous  congestion,  or  such  other  causes  as  may 
produce  the  same  result.  Even  dropsical  accumula- 
tion may  ensue,  but  as  the  cause  is  ordinarily  tempo- 
rary and  removable,  its  previous  occurrence  does  not 
decline,  and  its  presence  only  postpones  the  risk.  But 
enlargement  from  hepatic  venous  congestion,  with  or 
without  dropsical  effusion,  prevents  insurance,  because 
dependent  on  thoracic  obstruction  to  the  circulation. 
Unless  that  obstruction  is  proved  to  have  been  only 
temporary,  the  objection  is  a  fatal  one.  The  diagnosis 
between  these  two  forms  is  usually  readily  made  out, 
and  the  important  character  of  their  diversity  must 
fully  impress  the  Examiner.  The  enlargement  may 
be  due  to  abnormal  deposits  in  the  parenchyma — to 
determine  the  character  of  these  requires  attention  to 
the  history,  and  establishment  of  the  diathesis.  If  to 


112 

be  referred  to  abnormal  deposits  or  growths,  the  cast 
must  be  rejected. 

Atrophy  of  the  organ  is  generally  connected  with 
evidences  of  impaired  digestion  and  secretion,  which 
taken  with  the  history,  will  suffice  for  diagnosis.  In 
vastly  the  larger  proportion  of  cases  the  small  liver 
depends  upon  cirrhosis,  and  this  produced  by  habitual 
use  of  alcoholic  stimulants.  In  all  cases  this  condi- 
tion established,  even  without  symptoms  of  its  remote 
results,  denies  the  risk.  Its  most  obvious  concurrent 
symptoms  are  disturbance  of  the  stomach  and  obsti- 
nate diarrhoea.  The  superficial  veins  of  the  abdomen 
are  apt  to  be  enlarged ;  the  skin  is  sallow,  dry  and 
rough.  Dn  Budd  asserts  strongly  :  "  Slight  sallow- 
ness  of  complexion,  a  dull  pain,  or  some  degree  of 
tenderness  in  the  right  hypochondrium,  with  occasional 
feverishness,  in  a  person  above  the  age  of  thirty,  who 
has  been  long  in  the  habit  of  drinking  spirits  to 
excess,  are  almost  conclusive  evidence  of  the  existence 
of  cirrhosis,  even  before  there  is  any  distinct  proof 
that  the  circulation  through  the  liver  is  impeded." 

The  same  condition  of  the  organ  may  be  produced 
by  various  cachexiae,  particularly  malarious  and  syphi- 
litic poisoning,  caries  and  necrosis.  Whatever  the 
cause,  its  presence  rejects. 

Degeneration  of  the  parenchyma  of  the  organ  by 
fatty  or  amyloid  deposits,  begets  a  similar  train  of 

symptoms,   but  is  generally   associated  with   enlarge- 
ment  of  its    bulk.      The   diagnosis   is   facilitated   by 

reference  to    the  history  of  the  case  and  concurrent 
symptoms.        Both     involve     gastric      derangement^ 


tumidity  of  the  spleen,  diarrhoea  and  anaemia.  The 
fatty  degeneration  may,  however,  be  connected  with 
more  or  less  general  corpulence,  often  gained  rapidly, 
and  in  the  latter  case  is  always  suspicious.  From  what- 
ever cause  arising,  and  however  moderate  the  manifest 
symptoms,  both  varieties  reject. 

Acute  Atrophy  will  not,  from  the  activity  of  the 
symptoms,  be  presented  to  the  Insurance  Examiner. 

Chronic  Inflammation  of  the  viscus,  whether  superficial 
or  parenchymatous,  is  the  not  infrequent  result  of  resi- 
dence in  tropical  climates,  or  of  intemperate  habits, 
or  cachexiae.  While  present,  it  rejects,  whether  it  has 
yet  produced  either  hypertrophy,  or  atrophy,  or  any 
of  the  later  symptoms  of  the  disease.  It  is  well  to 
recollect  that,  under  the  influence  of  treatment,  the 
person  may  suppose  a  cure  to  have  been  effected,  and 
thus  present  himself  for  insurance.  Nevertheless,  the 
admitted  occasional  anorexia,  diarrhoea,  scanty  urine 
loaded  with  lithates,  sallowness,  dryness  and  roughness 
of  the  skin,  the  physiognomy  and  progressive  emaciation 
and  debility,  will  sufficiently  characterize  the  case. 

Jaundice  has  been  already  referred  to  (p.  27).  Since 
while  present,  in  all  cases,  it  at  least  postpones,  its 
differential  diagnosis  is  here  scarcely  necessary. 

THE  PANCREAS  is  rarely  diagnosticated  as  the  seat 
of  disease.  Its  enlargement  can  usually  be  determined 
by  palpation,  and,  from  whatever  cause,  declines  the 
risk.  The  increase  of  size  is  generally  accompanied  by 
tenderness,  a  sense  of  fulness  or  hardness,  heat  and 
constriction,  anorexia,  nausea  and  obstinate  vomiting, 
8 


H4 

or   inodorous    eructations,    emaciation,    debility,  and 
mental  depression. 

THE  SPLEEN  is  so  frequently  enlarged  permanently, 
without  any  evidences  of  derangement  of  health,  that 
unless  the  enlargement  is  excessive,  forming  abdominal 
tumor,  or  the  signs  of  malarious  or  other  cachexia  are 
present,  it  may  scarcely  be  considered  as  impairing  the 
lisk.  Nevertheless,  the  frequent  association  of  en- 
larged spleen,  with  degenerations  of  the  liver  and  other 
organs,  with  affections  of  the  lymphatic  glands,  with 
leukaemia,  phthisis,  etc.,  renders  it  incumbent  upon 
the  Examiner,  whenever  it  is  present,  to  make  a  mi- 
nute and  exhaustive  survey  of  the  organs  individually 
and  of  the  system  as  a  whole. 

THE  INTESTINAL  TUBE. — There  may  be  physical  ev- 
idences of  distension  of  the  intestines  by  tympanites, 
accumulated  faeces,  herniae  or  tumors.  But  the  atten- 
tion of  the  Examiner  is  rather  directed  to  the  condi- 
tion of  the  canal  by  historical  or  concurrent  symptoms 
which  indicate  its  condition.  Hernia  is  noticed  upon 
p.  31,  et  seq.  Heterologous  growths  of  any  variety  re- 
ject. Acute  affections  of  the  tube  postpone.  Chronic 
disorders  and  lesions  may  require  careful  investigation. 

The  most  frequent  cause  of  question  is  the  presence 
of  chronic  diarrhcea,  meaning  by  the  phrase  abnormal 
frequency  and  fluidity  of  the  alvine  evacuations, 
More  important  than  these  will  be  found  the  charac- 
ter of  the  discharge.  There  may  exist  a  chronic  ca- 
tarrhal  affection  of  the  mucous  membrane,  wherein, 
with  little  or  no  noticeable  disturbance  of  the  health, 
the  increased  frequency  and  fluidity  of  the  discharges 


is  kept  up  by  mere  habit  of  the  part,  in  accordance 
with  a  well  understood  physiological  law.  Or  it  may 
be  a  normal  individual  peculiarity.  In  such  a  case  the 
risk  may  not  be  invalidated.  But  the  fact  that  such  a 
condition  of  the  canal  very  generally  denotes  irregular 
habits  of  diet,  the  abuse  of  alcoholic  stimulants  or 
opium,  or  local  disease  of  the  adjuvant  or  remote 
organ,  suggests  caution,  (p.  40.) 

A  very  large  proportion  of  those  engaged  in  the  re- 
cent war  are  subject  to  this  form  of  diarrhoea,  which, 
subsiding  for  a  time,  is  readily  provoked  by  exciting 
causes.  In  the  absence  of  the  evidences  of  ulcerations, 
organic  affection  of  the  liver  or  kidneys,  scorbutus, 
tuberculosis  or  other  cachexia,  such  cases  need  not 
necessarily  be  rejected,  but  very  great  care  should  be 
exercised.  The  evidences  of  deficient  nutrition  afford- 
ed by  emaciation,  or  its  correlative,  fatty  degeneration, 
disqualify.  Thoracic  obstruction  to  the  circulation 
may  ultimate  in  diarrhoea,  and  hence  inquiry  is  directed 
to  the  heart,  lungs,  etc.  Deficient  frequency,  or 
consistence  of  the  evacuations,  points  to  the  mere 
habit  of  the  parts,  illustrating  rather  the  distensibility 
of  the  large  intestine  than  disease  ;  or,  it  may  remind 
of  mechanical  obstruction  by  bands  of  consolidated 
and  contracted  lymph  from  previous  enteritis,  or  her- 
nia, or  the  pressure  of  tumors,  or  hypertrophied  viscera, 
or  of  defective  secretions  from  the  mucuous  membrane, 
the  liver,  and  pancras,  etc. ;  or  of  the  benumbing 
influence  of  retained  excreta,  or  poisons  received  ;  or, 
deficient  innervation  from  central  disease  of  the  ner- 
vous apparatus.  The  varying  gravity  of  these  causes 


renders  their  differential  diagnosis  a  matter  of  great 
importance,  in  order  that  justice  may  be  done  both  to 
the  applicant  and  the  company. 

Among  the  lesions  of  the  tube  which  give  rise  to 
the  least  marked  symptoms,  and  yet  pregnant  of  grave 
consequences,  is  to  be  noticed  Atrophy  of  the  mucous 
membrane — a  condition  frequently  found  in  the  tardily 
convalescent,  and  in  those  laboring  under  a  more  or 
less  manifest  cachexia,  tuberculous,  syphilitic,  amyloid, 
etc.  This  may  be  present  without  apparent  diarrhoea, 
costiveness  or  constipation.  When  present  it  is  likely 
to  invade  the  entire  continuity  of  the  membrane. 
Often  all  the  symptoms  observed  are  referred  vaguely 
to  dyspepsia,  but  it  may  have  originated  in  a  true  cir- 
rhosis from  inflammation  extending  to  the  subjacent 
tissue.  From  whatever  cause  arising,  it  is  among  the 
reasons  for  rejection.  The  labial,  buccal  and  pharyn- 
geal  membrane  will  exhibit  the  imperfect  structure  to 
the  eye,  whilst  anaemia  and  debility  are  minatory,  if 
not  actually  present — without  seeming  cause.  There 
will  be  admitted  anorexia,  nausea  on  arising  from  the 
recumbent  position;  a  sensation  as  though  "food  was 
never  effectually  swallowed,  but  stuck  at  the  diaphrag- 
matic entrance  of  the  stomach,  causing  the  peculiar 
feeling  of  weight  which  attends  indigestion  and  the 
abundant  generation  of  gaseous  fluids." 

Haemorrhoids  are  occasionally  of  such  severity  and 
productive  of  such  exhaustion,  as  alone  to  preclude 
insurance,  but  ordinarily  they  refer  examination  to 
their  producing  cause,  which  is  usually  some  obstruc- 
tion to  the  return  of  blood  from  the  rectum.  Thus 


117 

habitual  constipation,  enlarged  uterus,  pelvic  or  abdo- 
minal tumors,  a  cirrhosed  or  congested  liver,  etc. 
Or  they  may  indicate  the  general  relaxation  of  the 
va.ve  structure  of  the  veins,  resulting  from  residence 
in  tropical  climates,  or  diseases  tending  to  produce 
congestion  of  the  pelvic  vessels. 

Chronic  Dysentery  is  noticed  on  page  40.  "The 
prognosis  is  never  very  favorable*' — but  the  diagnosis 
should  be  exact. 

In  a  general  survey  of  the  alimentary  canal  and  sub- 
sidiary organs,  the  relative  power  and  perfection  of  the 
nutrient  system  should  be  comprehensively  estimated. 
Upon  it  depends  the  entire  superstructure  of  organiza- 
tion. Its  condition  modifies  judgment  as  t;o  the 
probable  influence  of  both  hereditary  and  acquired 
predispositions.  It  influences  the  prognosis  as  to  the 
results  of  both  acute  and  chronic  disease.  Even  when 
organic  diseases  of  grave  character  are  unmistakably 
present,  as  developed  by  the  expert  diagnostician,  its 
high  degree  of  perfection  is  capable  of  masking  and 
concealing  the  rational  symptoms  usually  observable  in 
less  fortunate  cases.  Lesions,  ordinarily  confessed 
beyond  the  control  of  so-called  medicines,  sometimes 
disappear  under  the  healing  influence  of  healthy  blood 
furnished  to  them  by  a  powerful  digestive  apparatus. 
Thus  vigorous  digestion  may  aid  the  Examiner  in 
conscientiously  recommending  a  risk  which  has  some 
notably  objectionable  features.  Yet  the  same  condi- 
tion of  the  chylopoietic  viscera,  associated  with  organic 
changes,  may  add  weight  to  the  reasons  for  rejection. 
Witness  the  bruit  of  the  heart's  valves,  while  yet 


n8 

abdominal  health  is  undisturbed.  Witness  the  tu- 
berculous deposit  in  the  lung,  which  remains  un- 
heeded until  some  accidental  cause  impairs  digestive 
energy,  and  then  the  softening,  breaking  down,  and 
hectic  speedily  number  the  remaining  days  of  existence. 
The  judgment  of  the  Examiner  is  the  combined  result 
of  a  multitude  of  perceptions,  vivified  by  the  educated 
reasoning  faculty  —  as  the  body  of  man  is  made  up 
from  almost  innumerable  parts,  controlled  by  the 
single  principle  of  life. 

THE  KIDNEYS. — As  in  the  instances  previously 
cited,  acute  affections  of  the  renal  organs  do  not  come 
within  the  scope  of  a  life  insurance  examination,  but 
their  chronic  lesions  are  so  frequently  obscure  and  so 
frequently  misapprehended,  both  by  applicants  and  phy- 
sicians, and  at  the  same  time  they  are  so  dangerous  in 
tendency  that  the  Examiner  should  be  "armed  at  all 
points"  against  mistakes  in  regard  to  them. 

Enlargement  of  one  or  both  kidneys  from  hyper- 
trophy, cystic  or  heterologous  growths,  etc.,  may  be 
discoverable  as  abdominal  tumor.  Whatever  the 
differential  diagnosis,  such  cases  must  be  declined. 

Chronic  Inflammation  is  one  of  the  forms  of  Bright/ s 
Disease  to  be  presently  discussed.  It  is  noticed  here 
as  frequently  confounded  with  simple  nephralgia,  spinal 
irritation,  chronic  rheumatism  (lumbago),  gout  and 
scorbutic  pains.  The  chronic  nephritis  absolutely 
rejects. 

Nephralgia  is  often  but  the  evidence  of  a  tempo- 
rarily, highly  acrid  and  irritating  secretion,  or  a  "mis- 
placed gout ;  "  or  the  passage  of  what  may  prove  but 


H9 

a  single  renal  calculus ;  or  it  may  be  but  an  alternate 
of  neuralgia,  usually  occurring  in  other  parts,  the  effect 
possibly  of  malarious  disease.  It  may  be  the  tempo- 
rary result  of  medicines  or  poisons,  or,  as  in  small- 
pox, perhaps  from  irritation  of  the  specific  virus.  Or 
the  real  anguish  may  depend  on  enteritis.  The 
diagnosis  is  to  be  exclusive — absence  of  the  distinctive 
concurrent  symptoms  of  the  other  affections  noticed, 
must  be  determined.  Nephralgia  readily  passes  into 
nephritis,  and  unless  the  fact  of  its  occurrence  is  an 
isolated  one,  and  the  phenomena  definitely  traced  to  a 
removable  and  removed  cause,  it  should  decline. 
Recurrent  attacks  are  equally  objectionable  to  the  risk. 
(vid.  p.  35  et  seq.) 

BRIGHT'S  DISEASE,  OR  ALBUMINURIA.— Desquama- 
tive  nephritis  in  the  acute  form,  from  its  active  symp- 
toms, does  not  require  notice  here — but  the  chronic 
form  may  exist  for  a  long  time  without  marked  symp- 
toms, and  h^nce  a  liability  for  both  the  applicant  and 
the  Examiner  to  overlook  an  uninsurable  case  of 
disease.  Without  actual  sickness  there  may  be  gen- 
eral feelings  of  malaise,  with  imperfection  of  health 
and  general  debility.  Anorexia  or  capricious  appetite, 
with  gastric  and  intestinal  disorder,  vomiting  and 
diarrhoea,  usually  attributed  to  dyspepsia.  Progres- 
sive emaciation,  which,  however,  is  sometimes  con- 
cealed by  the  puffiness  of  anasarca,  most  noticeable  on 
the  face  and  eyelids,  but  gradually  becoming  general. 
The  urine  is  passed  more  frequently  than  usual — the 
patient  being  obliged  to  rise  in  the  night  for  the  pur- 
pose. The  urine  may  be  normal  in  its  appearance 


12O 

and  chemical  reaction,  but  microscopic  examination 
will  detect  in  the  sediment  disintegrated  epithelial  cells, 
or  even  fibrinous  casts  of  tubuli  uriniferi  from  the  kid- 
neys. The  general  aspect  of  the  party  will  show  the 
almost  indescribable,  but  nevertheless  characteristic 
physiognomy  of  renal  disease.  The  skin  is  dry, 
rough,  and  sallow  —  in  time  becoming  anaemic,  waxy, 
and  sodden.  There  are  evidences  of  oppression  in 
respiration  from  slight  oedema  of  the  lungs.  Frequent 
local  pains  —  most  frequently  cephalalgia,  but  invading 
any  part,  may  be  admitted,  but  are  referred  vaguely 
to  dyspepsia,  rheumatism,  or  neuralgia.  These  com- 
municate a  permanent  expression  to  the  facial  lines. 
Disorders  of  vision  are  not  infrequent,  and  the  expert 
ophthalmoscopist  can  sometimes  detect  on  the  retina 
evidences  that  the  supposed  local  affection  depends 
upon  organic  lesion  of  the  distant  kidneys.  Deaf- 
ness and  local  paralyses  elsewhere,  may  be  the  sole 
monitions  of  the  renal  affection.  Supposed  "  func- 
tional," but  ultimately  clearly  organic  cardiac  disease, 
may  mask  the  real  difficulty.  In  fine,  a  marked  pro- 
clivity to  local  inflammation  of  whatever  organ  or 
surface,  even  though  the  party,  at  the  time  of  the 
examination,  be  apparently  in  excellent  health,  lends 
color  to  suspicion  of  renal  imperfection. 

All  the  symptoms  here  recounted  may  be  present  in 
any  of  the  forms  of  Bright' s  Disease,  whether  resolved 
into  atrophy,  cirrhosis,  degeneration,  or  deposit. 
Save  in  so  far  as  the  accompanying  cachexia  of  each 
may  have  its  own  bearing  on  the  general  character  of 
the  risk,  their  differential  diagnosis  is  unnecssary. 


121 

Their  ultimate  result  is  the  same — uraemic  poisoning 
and  death,  which  may  be  hastened  by  the  concurrent 
affections  of  the  heart,  lungs,  liver,  general  or  local 
dropsy,  etc. 

The  prognosis  is  always  grave,  and  hence  the  sub- 
ject uninsurable,  even  though  temporarily  there  is  an 
absence  of  symptoms.  In  all  doubtful  cases  the  urine 
should  be  tested  in  its  specific  gravity,  its  chemical 
reactions,  and  microscopy  of  its  sediments.  The 
peculiar  fuliginous  appearance  sometimes  present, 
probably  from  some  chemical  change  in  the  haematin 
accompanying  the  desquamation,  will  readily  attract 
notice.  So  also  the  presence  of  albumen,  but  particu- 
larly the  low  specific  gravity,  and  the  sediment  com- 
posed of  the  epithelial  casts  and  disintegrated  blood 
cells.  The  tests  are  so  simple,  and  so  easily  applied, 
that,  while  interests  of  such  magnitude  are  in  issue, 
there  should  be  no  excuse  permitted  for  neglecting 
them.  Itk  should  be  borne  in  mind  that  Temporary 
Albuminuria  may  have  been  present,  in  connection 
with  previous  diseases,  and  yet  complete  recovery  have 
taken  place.  Thus,  in  connection  with  Scarlatina  and 
other  exanthems,  Cholera,  Pneumonia,  Rheumatism. 
Or  again  from  confinement  to  an  albuminous  diet. 
Occasionally,  also,  during  pregnancy.  Probably  in 
these  cases  there  has  been  no  considerable  or  continu- 
ous exfoliation  of  the  epitheliun  of  the  tubuli  uriniferi. 
Such  cases  may  not,  f~om  their  history,  impair  the 
risk.  But  it  is  unsafe  to  . .  :ept  a  case  of  present  albu- 
minuria,  even  though  there  *.:ay  be  strong  belief  that 
it  is  the  simple,  form. 


122 

Calculus  present  rejects.  Recurrent  attacks  also  for- 
bid the  risk.  But  it  may  be  recollected  that  popularly 
mere  vesical  pain  and  strangury  are  attributed  to  grav- 
el, and  hence,  when  this  is  spoken  of,  the  case  should 
be  further  tested. 

Chronic  Cystitis  and  Enlarged  Prostate  disqualify,  and 
so,  also,  during  its  existence,  Permanent  Stricture. 
These  lesions,  on  occurrence  of  slight  exciting  causes, 
may  eventuate  fatally.  Spasmodic  stricture  is  not 
infrequently  symptomatic  of  renal  lesion,  and  the 
chronic  inflammation  of  the  bladder  may  also  be  kept 
up  by  the  deranged  kidneys. 

DIABETES  may  be  noticed  in  this  connection, 
although  scarcely  to  be  considered  as  a  disease  of  the 
kidneys.  From  its  insidious  nature,  and  long  absence 
of  readily  cognizable  symptoms,  it  is  liable  to  be  over- 
looked both  by  the  party  applying  and  the  too  unob- 
servant Examiner.  Aside  from  the  varying  influences 
which,  within  the  limits  of  health,  may  increase  or 
diminish  the  amount  of  urine  excreted,  any  undue 
quantity  habitually  passed  should  direct  attention. 
Whether  saccharine  or  not,  the  undue  amount  post- 
pones. If  repeated  tests  show  the  presence  of  sugar, 
or  abnormal  specific  gravity,  the  risk  must  be  declined. 
Absence  of  these,  and  increased  amount,  suggest 
Bright's  Disease. 

The  skilled  Examiner  may  often  detect  early  the 
rational  symptoms  of  the  affection.  The  skin  is  dry, 
rough  and  shrunken,  with  a  tendency  to  morbid  nutri- 
tion of  its  appendages,  or  boils  and  carbuncles.  Dry- 
ness,  also,  of  the  buccal  membrane,  with  shrinkage  of 


the  gums.  Unusual  thirst  and  inordinate  appetite, 
often  resulting  in  distended  stomach.  Constipation, 
with  dense  and  friable  faeces.  The  odor  of  the  breath 
sweetish,  or,  as  has  been  suggested,  chloroformic. 
Gradual  emaciation,  with  muscular  debility,  and,  occa- 
sionally, local  paralyses.  Slight,  mental  hebetude, 
with  languid  movements.  Critical  questioning  may 
elicit  the  presence  of  diminished  sexual  desire  and 
energy.  In  very  many  instances  there  mav  be  super- 
added  the  signs  of  hepatic  degeneration,  and,  always, 
disorder  of  the  nervous  system,  manifesting  itself  in 
all  phases,  from  mere  dullness  to  irascibility,  peevish- 
ness, capriciousness  and  monomania.  By  these  ner- 
vous phases  of  the  disease,  the  emaciation,  and  rough, 
dry  integument,  there  is  a  'physiognomy  impressed  upon 
the  person  which  can  scarcely  escape  the  notice  of  the 
careful  Examiner.  In  such  cases  the  urine  should  be 
chemically  tested  by  the  most  approved  modern 
methods. 

It  is  unnecessary  to  refer  to  the  causation  of  dia- 
betes, for  its  rational  symptoms,  when  strongly  .marked, 
would  cause  rejection,  whatever  their  cause,  and  the 
chemical  evidences  of  its  presence  are  totally  exclusive. 

ADDJSON'S  DISEASE,  or  that  peculiar  anaemic  condi- 
tion, with  gradual  bronzing  in  the  color  of  the  skin 
which,  within  several  years  past,  has  attracted  the 
investigation  of  pathologists,  need  not  here  receive 
more  than  a  passing  notice.  When  it  is  possible  to 
achieve  an  exact  diagnosis,  the  concurrent  symp- 
toms will  alone  be  sufficient  to  establish  general 
disqualification. 


I24 

VI. 

Cerebro-NerVQUS  System — Very  many  of  the  nota- 
ble disturbances  of  the  orderly  manifestations  of  the  cer- 
ebro-nervous  apparatus,  are  directly  traceable  to  errors 
in  action  of  the  digestive  organs.  Hence  consid- 
eration of  the  former,  to  be  satisfactory  in  result, 
demands  complete  survey  of  the  latter.  Again,  it 
often  occurs  that  the  apparent  disorders  of  a  part,  or 
even  the  whole,  of  the  nervous  system,  may  depend 
upon  reflex  influences — local  derangement  of  a  single 
point  begetting  a  train  of  symptoms  which  may  be 
mistaken  for  those  dependent  on  organic  lesion  of  the 
nervous  centres.  Evidently,  therefore,  any  judgment 
formed  with  reference  to  the  symptoms  only,  is  liable 
to  be  erroneous.  Aberrations  of  nervous  manifesta- 
tions, if  dependent  on  organic  disease  of  the  nervous 
centres,  while  present  utterly  disqualify  —  whatever 
their  extent.  But,  if  owing  their  origin  solely  to 
blood  imperfectly  formed,  or  rendered  noxious  by  re- 
tained excreta,  or  poisonous  material  introduced  into 
it,  or,  from  reflex  influences  from  lesions  in  other  or- 
gans or  tissues,  the  judgment,  obviously,  is  to  be 
shaped  by  considerations  affecting  the  importance,  ex- 
tent, character,  permanency  or  removability  of  the 
cause.  This  will  thoroughly  tax  the  skill  of  the 
Examiner. 

It  is  well,  in  analysis  of  this  branch  of  the  subject, 
so  far  as  it  falls  within  the  scope  of  the  present  essay, 
to  adopt  the  simplest  possible  divisions.  Thus  we 
consider:  Derangements  of  Motion,  whether  of  the 


I25 

voluntary  or  involuntary  muscles  ;  Derangements  of 
Sensation,  whether  common  or  special ;  Derangements 
of  Mental  Action,  whether  of  the  reason,  or  of  the 
emotions. 

DERANGEMENT  OF  MOTION. — Tremulousness,  Tre- 
mors, Spasms,  Convulsions,  Error  of  Co-ordination, 
Rigidity,  Paralyses,  severally  indicate  a  greater  or  less 
disorder  of  the  nervous  apparatus.  It  is  necessary  to 
inquire  whether  that  disorder  be  dependent  on  local 
or  general  causes ;  whether  it  depend  on  nutrition,  on 
toxaemia  from  retained  excreta,  or  poisons  taken  into 
the  blood  from  without,  or  upon  organic  changes  at 
the  nervous  centre. 

Tremor,  or  tremulousness,  may  be  due  merely  to  the 
changes  of  advanced  age.  If  this  sign  of  age  comes 
prematurely,  the  premature  age  marks  a  condition  of 
the  system,  as  a  whole,  which  lessens  the  desirability 
of  the  risk.  Very  frequently  it  is  dependent  on  the 
use  of  tea,  coffee,  opiates  or  alcoholic  stimulants;  being 
the  result  of  their  action,  although  temporarily  re- 
lieved by  them.  Concurrent  symptoms  here  must  be 
carefully  scanned.  The  tremors  of  the  opium  eater, 
or  spirit  drinker,  whilst  deprived  of  the  accustomed 
stimulus,  should  determine  rejection.  Metallic  pois- 
oning, as  from  lead,  mercury,  etc.,  may  give  the  same 
result.  Concurrent  symptoms  may  determine  morbid 
nutrition,  or  exclusive  diagnosis  may  refer  the  feeble 
muscular  agitation  to  central  disease  of  the  brain  or 
spinal  cord.  But  meanwhile  it  may  be  a  nervous 
idiosyncrasy,  or  temporarily  the  result  of  reflex 
influences,  from  removable  disease  of  remote  organs. 


126 

Convulsions,  or  Spasms,  sometimes  readily  occur  in 
persons  of  a  highly  mobile  nervous  temperament. 
Hysterical  females  are  especially  liable  to  them,  but 
males  are  not  exempt.  Like  the  milder  symptom 
just  noted,  they  majy  be  of  centric  or  eccentric  origin. 
But  ordinarily,  when  occurring  without  other  evidences 
of  cerebro-spinal  lesion,  they  may  be  adjudged  of  ec- 
centric origin.  Among  the  causes  of  the  latter  variety, 
may  be  mentioned  dental  and  intestinal  irritation, 
more  frequent  in  children,  but  not  confined  to  them. 
Uterine,  vesical  and  rectal  irritation  in  the  adult. 
Contaminated  blood,  from  retained  excreta  or  poisons, 
and  powerful  emotional  influences.  Among  the  cen- 
tric causes,  we  advert  to  mal-nutrition  of  the  brain, 
or  its  inflammation,  deposits,  morbid  growths,  sudden 
interference  with  the  cerebral  circulation,  as  by  emboli, 
the  shock  of  injury,  haemorrhage,  effusions,  etc. 

Epilepsy,  one  of  the  forms  of  convulsive  action,  is 
distinguished  prominently  by  its  tendency  to  recur  at 
intervals,  which  may  be  more  or  less  distinctly  periodic. 
The  period  between  the  paroxysms  may  show  no 
marked  derangement  of  health,  although,  unfortu- 
nately, there  is  likely  to  be  mental  hebetude  and  tardy 
development  of  all  normal  bodily  action.  Its  pecu- 
liar suspension  of  consciousness  serves  to  assist  in 
diagnosing  it  from  hysterical,  and,  indeed,  most  forms 
of  convulsions.  True  epilepsy  always  excludes,  what- 
ever its  supposed  cause.  Convulsions  from  other 
causes,  must  be  measured  by  them,  their  permanence 
or  removability,  and  by  concurrent  evidences  regard- 
ing their  centric  or  eccentric  origin,  and  the  respective 


I2-/ 

bearings  of  these,  rather  th?.i  che  accidental  symptom, 
Generally  speaking,  recurrent  convulsions,  even  from 
clearly  mild  and  removable  causes,  should  postpone 
until  the  tendency  to  them  has  entirely  subsided. 
Local  convulsive  action  of  greater  or  less  intensity 
and  duration,  accompanied  with  numbness  and  inability 
to  move  the  part — or  cramp,  as  popularly  designated, 
is  sufficiently  common  to  persons  in  good  health,  and 
need  not  necessarily  disqualify.  But  its  occasional 
occurrence  among  the  initiatory  symptoms  of  central 
nervous  lesions,  or  of  metallic  poisoning,  or,  as  reflex 
from  important  remote  organic  disease,  suggests  in- 
quiry into  the  real  meaning. 

Defective  Co-ordination  of  the  movements  as  exem- 
plified in  Chorea,  but  present  in  other  cases  without 
the  intensity  of  contraction  observable  in  that  disease, 
points  to  a  similar  train  of  inquiries  as  to  its  causa- 
tion. It  is  often  one  of  the  most  insidious  of  diseases, 
occupying  months  or  years  in  its  full  development. 
Thus  in  Duchenne's  "Progressive  Locomotor  Ataxia" 
characterized  by  long  antecedent  impairment  of  vision, 
with  inequality  of  the  pupils,  with  wandering,  brief 
but  piercing  pains,  —  "like  electric  flashes" — then 
vertigo  and  difficulty  in  maintaining  the  equilibrium, 
and  in  co-ordinating  the  movements,  with  local  anaes- 
thesia or  paralyses.  Functional  concurrent  disorders 
of  the  bladder  and  rectum.  The  necessity  of  a  strong 
effort  of  the  will,  in  connection  with  the  usually  im- 
paired eyesight,  impresses  an  unmistakable  physiog- 
nomy on  the  case.  Owing  its  causation,  as  it  probably 
does,  to  atrophy  or  degeneration  of  the  great  nervous 


128 

centres,  and  its  prognosis  always  being  grave,  its 
incipient  signs  should  be  carefully  explored. 

Rigidity  of  the  muscles  is  closely  akin  to  paralysis. 
It  may  involve  but  few  muscles,  or  as  many  as  in  half 
the  body.  It  is  so  generally  associated  with  organic 
disease  of  the  brain,  especially  ramoltissement  that,  un- 
less traceable  positively  to  some  local  cause,  it  must 
exclude. 

Paralysis,  if  involving  any  considerable  portion  of 
the  body,  as  hemiplegia  or  paraplegia,  inexorably  must 
meet  with  refusal.  But  many  cases  of  local  palsy, 
from  definite  local  causes  only,  are  not  debarred  in- 
surance. Thus  where  a  nerve  has  been  divided  by 
accident  or  surgical  operation ;  the  pressure  of  a  re- 
movable tumor  or  growth ;  the  presence  of  some  for- 
eign substance,  as  a  bullet  or  splinter,  etc.;  or,  wherever 
clearly  referrible  to  the  local  lesion  alone.  Again, 
paralysis,  as  well  as  convulsions,  may  be  reflex,  and 
the  lesion  at  the  excitor  point  be  capable  of  relief. 
Local  vicissitudes  may  beget  a  local  paralysis  of  mo- 
tion, as  when,  e.  g.y  the  facial  muscles  of  one  side  are 
temporarily  paralyzed  by  exposure  to  a  draft  of  air. 
In  like  manner  the  muscles  of  articulation  may,  by 
paralysis,  beget  aphonia.  Pressure  on  a  nerve  from 
mere  position,  local  shock  from  a  blow,  or  common 
inflammation  may  ensue  in  palsy  of  the  parts  to  which 
that  nerve  is  distributed.  Such  cases  need  not  neces- 
sarily be  rejected,  but  the  large  proportion  of  cases, 
wherein  this  symptom  is  a  concurrent  one  of  diseases 
of  the  brain  or  spinal  cord,  requires  the  most  minute 
and  exhaustive  research.  Occasionally  it  may  happen 


129 

that  the  loss  of  mobile  power  will  be  found  dependent 
on  the  influence  of  some  pervading  poison,  e.  g.  lead, 
toxaemia,  etc. 

DERANGED  SENSATION  may  be  observed  as  affecting 
nerves  of  common  or  special  sense.  Of  the  former, 
pain  is  the  prominent  exponent ;  but  sensations  of 
heat  or  cold,  itching,  tingling,  formication,  pressure, 
etc.,  may  co-exist,  or  be  the  sole  manifestation.  Mu- 
tatis mutandis,  the  same  considerations  enter  into  exam- 
ination of  the  case,  as  in  instances  of  deranged  motion. 
There  is,  however,  this  important  diversity,  that  the 
intensity  of  deranged  sensation  has  no  such  constant 
relation  to  the  severity  of  the  cause  as  exists  in  dis- 
ordered movements.  The  commingling  of  mental 
emotions  may  magnify  or  diminish  the  real  importance 
of  the  symptom.  It  is  well  remarked:  "That  acute 
sensibility  is  not  of  necessity  inflammatory,  is  one  of 
the  triumphs  of  modern  pathology." 

Diminished  sensation  is  more  analogous  in  its  indi- 
cations to  paralysis  of  motion,  than  is  hyperaesthesia 
to  tremor  or  convulsion.  It  is  more  liable  to  be  con- 
nected with  central  organic  disease,  or  some  over- 
powering general  poison.  Extended  anaesthesia,  over 
a  considerable  surface,  is  exceedingly  apt  to  be  con- 
necte  ..  with  central  ganglionic  nervous  lesion.  But 
sometimes  even  the  small  and  circumscribed  part, 
whicn  has  become  thus  affected,  is  among  the  premon- 
itory evidences  of  brain  or  spinal  disease.  In  such 
cases  the  method  of  exclusive  diagnosis  will  clear  up 
the  difficulty.  It  may  depend  on  local  influences,  upon 
poisons  in  the  blood,  or  other  abnormal  conditions  of 


that  fluid,    (e.  g.  rheumatism),   or  be  the  characteristic 
symptom  of  certain  cutaneous  eruptions. 

The  Special  Senses  may  present  a  similar  variety  of 
perversions  from  merely  local  causes,  reflex  influences, 
impaired  or  poisoned  blood,  or  central  disease  of  the 
brain. 

DERANGED  INTELLECTION  acknowledges  the  same 
variety  of  causation,  and  while  present  positively  de- 
clines the  risk,  whichever  may  have  been  the  imme- 
diate source  of  disturbance. 

DISEASES.  —  Among  the  forms  of  disease  of  the 
brain,  against  which  the  Insurance  Examiner  must  put 
himself  on  guard,  as  liable  to  be  masked  by  general 
indications  of  fair  health,  are  to  be  noted :  Chronic 
Meningitis,  Apoplexy,  Deposits  or  Growths,  Ramol- 
lissement,  Insanity,  Atrophy,  and,  not  the  least  in 
frequency,  Chronic  Poisoning.  As  affections  of  the 
Spinal  Cord :  Chronic  Inflammation,  Softening,  De- 
generation, or  other  evidences  of  its  deranged  nutrition. 

ENCEPHALITIS  of  the  acute  form  possesses  suffi 
ciently  distinctive  symptoms.  But  it  may,  frorr 
the  beginning,  be  sub-acute,  and  readily  lapses  intc 
the  chronic  character.  In  the  latter  case,  the  brair. 
substance  is  likely  to  become  implicated,  with  more 
or  less  modification  of  phenomena  presented.  There, 
may  be  very  slight  vascular  or  general  disturbance,  but 
careful  investigation  may  detect  more  or  less  distinct 
evidences  of  lesion.  If  the  pulse  is  perceptibly  affect- 
ed, it  is  likely  to  be  slower,  or  irregular  and  intermit- 
tent. A  little  impairment  of  the  special  senses  ;  i< 
may  be  hesitation  or  stammering  in  articulation,  which 


afterward,  perhaps,  will  deepen  into  complete  aphasia, 
constant,  deep-seated  headache,  nausea  and  vomiting, 
general  malaise;  some  stiffening  of  particular  muscles; 
limited  paralysis,  either  of  motion  or  sensation,  or 
both ;  sluggish  action  of  the  secretory  organs,  with 
constipation  and  unusual  retention  of  urine.  Some 
peculiarity  of  mental  manifestation,  "eccentricity," 
hypochondria,  or  preternatural  elevation  of  spirits,  or 
unusual  proclivity  to  entertain  false  or  absurd  notions. 
Restless  vigilance  may  alternate  with  profound  sleep, 
with,  ordinarily,  stertorous  respiration.  The  occur- 
rence of  previous  traumatic  injury  of  the  head,  or  of 
some  disease  tending  to  affect  the  brain,  will  throw 
light  on  the  diagnosis.  Location  of  the  cause  of 
these  symptoms  in  the  brain,  will  frequently  require 
the  exclusive  method  of  diagnosis. 

APOPLEXY. —  Undoubted  apoplexy  previously  occur- 
ring, although  the  party  be  now  in  apparently  perfect 
health,  peremptorily  rejects.  The  Life  Insurance 
Examiner  is  called  upon  rather  to  study  premonitions 
—  the  forerunners  of  the  lesion  before  it  makes  its 
appearance.  The  apoplectic  habit  is  popularly  sup- 
posed to  be  one  where  there  is  corpulency  with  a  short 
neck,  a  florid  face,  and  injected  conjunctiva  ;  the  latter 
appearances  more  marked  in  cases  of  excitement,  and 
accompanied  with  a  sensation  of  fullness  of  the  head, 
or  vertigo  and  throbbing  of  the  carotid  and  temporal 
arteries.  If  apoplexy  occurs  in  individuals  of  this 
physique,  it  is  rather  because  of  fatty  degeneration  of 
the  organs,  than  the  condition  of  rude  health  supposed 
present.  Or,  as  in  very  many  cases  reported,  there 


was  uraemia  or  other  toxaemic  causes  of  congestion  of 
the  brain,  mistaken  for  real  apoplexy.  The  tendency 
to  the  so-called  congestive  or  serous  apoplexies,  is  to 
be  elucidated  by  studying  the  mal-action  of  the  nutrient, 
secretory  and  excretory  organs. 

True  apoplexy  involves  haemorrhage  into  the  tissue 
or  cavities  of  the  encephalon,  and  this  presupposes 
degeneration  of  the  tissue  involving  the  coats  of  the 
supplying  arteries,  or,  the  originating  lesion  may  be 
confined  to  the  arterial  wall.  The  symptoms  of  real 
apoplexy  are  closely  simulated  by  the  detachment  of 
embolon,  and  its  projection  into,  and  consequent 
closure  of,  some  important  artery  of  supply.  The 
existence  of  aneurism,  save  from  simply  traumatic 
causes,  always  should  suggest  examination,  so  far  as 
possible,  of  all  the  arterial  trunks.  Whatever  inter- 
feres with  the  activity  of  the  circulation,  when  the 
arterial  parietes  are  weakened  by  calcareous  or  other 
abnormal  deposits,  by  fatty  degeneration  or  arteritis, 
etc.,  may  at  once  involve  apoplectic  seizure  in  the 
midst  of  apparent  high  health.  Thus  muscular  efforts, 
mental  influences,  especially  of  the  emotional  kind, 
disordered  digestion,  stimulants  or  narcotics,  febrile 
accessions,  retained  excreta,  etc.  Not  only  persons  of 
"full  habit,"  but  those  of  spare  frame,  long  necks 
and  scant  blood,  may  die  of  it  from  similar  exciting 
causes.  There  may  be  none  of  the  commonly  sup- 
posed prodromata  present,  and  yet  the  party  be  on  the 
verge  of  an  attack.  Something  more  than  head  symp- 
toms are  to  be  looked  for.  When  "shadows  are  cast 
before/'  they  are  manifested  "by  great  depression  of 


spirits,  by  attacks  of  loss  of  memory,  by  illusions,  by 
vitiated  perceptions,  by  vertigo,  by  odd  sensations  in 
the  head ; "  but  these  are  rather  the  indications  of  the 
degeneration  than  of  the  coming  apoplectic  seizure. 

DEPOSITS  or  GROWTHS  of  an  abnormal  character 
will,  vary  in  the  symptoms  presented,  according  to  the 
part  of  the  encephalon  invaded,  and  the  degree  of 
mischief  or  size  of  growth.  The  symptoms  are  often 
obscure,  and  their  character  opined  from  the  diathesis 
or  cachexia  present.  Exclusive  diagnosis  is  the  most 
satisfactory ;  the  most  common  symptoms  being 
<c  headache,  sickness,  mental  depression  with  confu- 
sion, partial  paralysis,  and  epileptiform  convulsions." 

ATROPHY  of  the  encephalon  is  usually  the  condition 
of  senility ;  but  it  may  occur  in  the  child  or  adult,  as 
the  result  of  those  lesions  which  cut  off  the  supply  of 
blood  —  e.  g.  pressure  of  tumors  or  growths,  embolon, 
ligature  of  arteries,  etc.  Advancing  insidiously,  it  may 
ultimate  in  utter  dementia. 

HYPERTROPHY  is  very  rare,  but  sometimes  is  no- 
ticed in  adults  between  twenty  and  thirty.  It  seems 
more  probable  that  what  is  denominated  hypertrophy 
of  the  brain,  is  rather  a  disease  of  its  bony  case,  in- 
volving replacement  of  the  cartilaginous  substance,  by 
abnormal  calcareous  deposit.  Hence,  the  unchanging 
cranial  wall  develops  the  effects  of  gradual  and  pro- 
longed pressure  upon  the  contents.  This  increased 
density  and  hardness  of  the  bone  is  gained  at  the  ex- 
pense of  its  elasticity,  and  hence,  in  such  cases,  there 
is  unusual  fragility  of  the  bones  everywhere.  Repeated 
fractures  of  bones  from  slight  causes,  with  any  of  the 


'34 

ordinary  evidences  of  cerebral  disorder,  direct  atten- 
tion to  the  condition  described.  It  is  fatal  to  the 
risk. 

SOFTENING  (Ramollissemeni)  of  the  encephalon  is  one 
of  the  most  covert  and  insidious  and,  at  the  same  time, 
one  of  the  most  frequent  and  dangerous  lesions  of  the 
brain  which  the  Examiner  is  called  upon  to  discover. 
Noticeable  enough  in  the  acute  form,  it  may  advance 
from  utter  obscurity  with  steps  so  treacherous  and 
and  stealthy,  that  only  the  wariest  observer  can  gain  a 
clue  to  its  presence,  or  avoid  sometimes  confounding 
it  with  trivial  affections.  Softening  may  occur  as  one 
of  the  results  of  acute  inflammation,  or,  as  a  conse- 
quence of  senility.  But  without  any  such  history  it 
may  come  on  gradually,  at  any  age,  as  the  result  of 
those  causes  which  beget  local  or  general  degeneration. 
Thus  mal-nutrition,  diseased  arteries,  emboli,  typhoid 
or  other  deposits,  fatty  degeneration,  etc.  The  func- 
tional disorder  of  the  brain,  taken  with  the  concurrent 
symptoms,  will  clear  up  the  diagnosis.  The  evidences 
of  chronic  (white)  softening  are  similar  to  those  of 
the  acute  inflammatory  (red)  form,  differing  mainly 
in  their  intensity  and  duration.  The  great  difficulty 
is  in  assigning  due  weight  to  those  diseases  of  other 
organs,  to  which  the  brain  symptoms  may  be  only 
secondary,  and  here,  again,  the  exclusive  method  of 
diagnosis  becomes  indispensable.  Unless  clearly  at- 
tributable to  remote  lesions  of  a  removable  character, 
a  case  which  has  presented  suspicious  brain  symptoms 
should  be  declined.  Among  these  suspicious  symp- 
toms, we  note  paroxysmal  headache,  aggravated  by 


'35 

noise,  light,  exercise,  etc.;  nausea  and  vomiting  with, 
generally,  constipation,  which  are  not  traceable  to 
deranged  digestion;  lessened  sensibility  of  the  blad- 
der ;  vertigo,  nervousness,  hypochondria,  diminution 
of  mental  powers,  with  obtuseness  of  special  sensa- 
tion. Sensations  of  "prickings  and  twitchings  in  the 
limbs,  sometimes  pain,  and  sometimes  numbness." 
Local  cramps,  and  more  or  less  permanent  rigidity  of 
particular  muscles.  General  feebleness  of  the  muscu- 
lar sjystem,  and  hebetude  of  all  the  faculties.  A  feeble, 
irregular  and  intermittent  pulse.  The  party  may  con- 
fess difficulty  in  "collecting  his  ideas"  —  there  is  a 
little  hesitancy  of  speech,  a  little  delay  in  answering 
questions  —  a  little  appearance  of  abstraction,  and  the 
articulation  not  quite  perfect. 

If  historically  there  has  been  some  disease  or  ca- 
chexia  present,  which  notably  affects  the  encephalon  — 
some  local  injury  from  a  fall,  or  blow,  or  surgical 
operation,  and  especially  if  the  age  is  above  fifty — 
the  diagnosis  is  strengthened,  that  softening,  or  some 
equally  important  lesion  of  the  brain,  is  present. 
The  -physiognomy  of  the  affection  is  very  impressive ; 
in  fact,  scarcely  to  be  mistaken. 

In  passing  it  may  be  remarked,  that  a  condition 
very  analogous  to  chronic  softening,  with  its  attend- 
ant symptoms,  is  very  frequently  observable  after  se- 
vere COUP  DE  SOLEIL.  In  cases  of  the  latter  the 
prognosis  is  not  as  grave,  nevertheless,  as  it  is  capable 
of  passing  into  actual  ramollissement,  with  paralysis, 
insanity,  etc.,  wherever  the  party  has  been  so  affected, 
the  examination  should  be  cautious  in  the  extreme. 


'36 

CHRONIC  POISONING  of  the  brain  may  occur  from 
the  habitual  use  of  Alcoholic  Stimulants,  Opium, 
Tobacco,  "Hasheesh/'  even  Tea  and  Coffee,  and,  in- 
deed, a  great  variety  of  agents  taken  for  the  purpose 
of  exhilaration  or  soothing.  During  the  use  of  the 
narcotic,  the  individual  may,  so  far  as  external  indica- 
tions are  concerned,  be  on  the  level  of  perfect  health ; 
but,  let.  any  accidental  physical  cause  interfere  with  its 
usual  impression,  or  let  its  use  be  suspended,  and  the 
condition  of  Nervous  Asthenia  immediately  super- 
venes. A  similar  condition  is  often  observable  in 
those  whese  mental  faculties  have  been  overwrought, 
and  it  engenders  an  almost  uncontrollable  desire  for 
stimulants  or  anodynes — which  latter  then  get  the 
discredit  of  its  production. 

"Physicians,"  says  Dr.  Flint,  "are  often  consulted 
by  patients  who,  although  far  from  being  well,  have 
no  well-defined  malady.  They  complain  of  languor, 
lassitude,  want  of  buoyancy,  aching  of  the  limbs,  and 
mental  depression.  They  are  wakeful  during  the 
night,  and  enter  upon  their  daily  pursuits  with  a  sense 
of  fatigue.  Under  the  pressure  of  mental  excitement, 
they  may  be  able  to  exert  themselves,  but,  when  the 
excitement  subsides,  they  are  jaded  and  worn  out. 
They  become  apprehensive  that  their  powers  are  giv- 
ing way,  and  are  apt  to  fancy  the  existence  of  some 
serious  malady.  An  investigation  of  the  different  or- 
gans of  the  body  reveals  no  evidence  of  disease ;  the 
lungs,  heart,  kidneys,  etc.,  are  sound.  None  of  the 
affections  embraced  in  the  nosological  catalogue  may 
be  discovered,  yet  the  morbid  condition  is  real/' 


'37 

A  person  in  this  condition  is,  clearly,  laboring  un 
der  the  result  of  undue  changes  in  the  minute  structure 
of  the  brain,  precisely  analogous  to  those  which  occur 
from  chronic  poisoning.  The  expert  Examiner  will 
recognize  the  symptoms  when  present,  or,  if  tempo- 
rarily held  in  abeyance  by  the  accustomed  excitation, 
will  scan  closely  the  history,  as  given  by  the  applicant 
and  sustained  by  the  friend  and  physician.  Although 
the  prognosis,  under  correct  therapeutic  and  hygienic 
treatment,  may  be  pronounced  by  the  physician  not 
grave,  the  uncertainty  of  this  being  carried  out,  and 
its  dangerous  tendency  if  neglected,  precludes,  utterly, 
acceptance  of  the  risk. 

Delirium  Tremens,  Dipsomania,  etc.,  previously  exist- 
ent, imperil  the  risk.  It  is  only  after  the  lapse  of  a 
long  period  of  time  and  great  weight  of  collateral 
moral  evidences  of  reform,  that  a  party  who  has 
suffered  from  them  can  be  accepted. 

INSANITY. — Some  general  observations  on  this  sub- 
ject have  been  made  on  page  25,  et  seq.  In  this 
place,  we  refer  rather  to  the  detection  of  incipient  or 
of  masked  insanity.  The  importance  of  this  topic 
demands  that  it  shall  receive  the  most  careful  attention 
of  the  Examiner.  Distinct  cases,  or  those  connected 
with  obvious  disease  of  the  nervous  centre,  of  course 
will  not  be  presented  for  insurance.  But  the  cunning 
maniac,  with  proverbial  ingenuity,  has  been  known  to 
outwit  examiners,  and  secure  large  policies  upon  his 
dangerous  life.  Hence,  clear  ideas  upon  its  diagnosis 
become  as  indispensable  to  the  Insurance  Examiner  as 
to  the  Medical  Jurist. 


•3* 

The  Family  History  first  calls  attention  to  the 
point,  as  it  is  well  recognized  as  one  of  the  most  com- 
monly transmissible  of  affections.  It  is  safe  to  say 
that  in  from  one-third  to  one-half  of  all  cases  of  obvious 
insanity,  its  presence  in  the  family  within  three  genera- 
tions can  be  traced.  If  those  slight  aberrations  of 
mind  or  eccentricities,  which,  from  absence  of  existing 
causes,  do  not  deepen  into  such  mania  as  requires 
treatment,  were  taken  into  account,  the  proportion 
would  certainly  be  largely  increased. 

Atavism  is  here  frequently  witnessed.  Baillarger's 
propositions  appear  to  be  generally  confirmed  : 

"  The  insanity  of  the  mother,  as  regards  transmis- 
sion, is  more  serious  than  that  of  the  father ;  not  only 
because  the  mother's  disorder  is  more  frequently  he- 
reditary, but  also  because  she  transmits  it  to  a  greater 
number  of  children. 

"  The  transmission  of  the  mother's  insanity  is  more 
to  be  feared  with  respect  to  the  girls  than  the  boys ; 
that  of  the  father,  on  the  other  hand,  is  more  dan- 
gerous as  regards  the  boys  than  the  girls. 

"  The  transmission  of  the  mother's  insanity  is 
scarcely  more  to  be  feared,  as  regards  the  boys,  than 
that  of  the  father ;  the  mother's  insanity,  on  the 
contrary,  is  twice  as  dangerous  to  the  daughters." 

To  these  it  may  be  added  that  the  insanity  of 
brothers  and  sisters  respectively,  is  a  matter  of  even 
more  import,  as  establishing  the  family  proclivity, 
than  that  of  parents. 

The  hereditary  tendency  follows  the  same  law  as 
other  inherited  tendencies,  as  to  its  occurrence  at 
certain  ages.  (Fid.  pp.  8  and  47.) 

A  similar  rule  obtains  as  to  resemblances  between 
parents  and  particular  children,  (p.  46.)  Owing  to 


'39 

the  absence  of  exciting  causes,  the  hereditary  predis- 
position may  never  have  been  manifested  in  any  strik- 
ing derangement,  and  yet  the  observant  Examiner  may 
notice  in  the  temperament,  in  the  habits  of  life,  in 
the  occupation,  the  peculiar  features  of  intercurrent 
diseases,  domestic  or  civil  troubles,  etc.,  additional 
reasons  for  declining  the  risk.  Pursuits  which  subject 
to  great  mental  <c  wear  and  tear,"  and  intemperance, 
are  among  the  most  potent  of  predisposing  influences. 
Many  cases  are  vaguely  attributed  to  religious  excite- 
ment, grief,  joy,  fear  or  other  emotions,  but  it  is  safe 
to  assume  that  when  insanity  ensues  upon  them,  it  is 
because  the  nervous  centre  is  already  on  the  brink  of 
disease. 

There  are  unusual  difficulties  attendant  upon  the 
decision  in  suspicious  cases.  But  the  Examiner  at 
least  escapes  the  necessity  of  determining  the  differ- 
ence between  feigned  and  real  insanity.  The  trouble 
*vill  be  in  baffling  the  great  ingenuity  with  which  the 
party  will  often  conceal  the  mental  disorder.  As 
Bucknill  and  Tuke  remark : 

cc  The  dread  of  insanity  in  many  families  of  this 
kind  is  so  great  as  to  constitute,  in  itself,  a  morbid 
feeling  sufficiently  strong  to  mislead  the  observation, 
to  warp  the  judgment,  and  to  occasion  sins  of  con- 
cealment and  untruthfulness  towards  those  who  have 
a  right  to  expect,  and  to  demand  the  fullest  and  most 
explicit  confidence." 

Next  to  the  hereditary  predisposition,  may  be  men- 
tioned that  arising  from  the  temperament,  either  orig- 
inal or  acquired.  Although  examples  of  insanity  may 
be  found  in  any  described  temperament,  yet  in  the 


140 

Sanguine  or  Phlegmatic  they  are  about  invariably  con- 
nected vith  notable  organic  lesion.  In  the  pure  Ner- 
vous temperament,  or  particularly  in  the  Bilio-Nervous 
or  Melancholic  variety,  it  is  apt  to  occur  with  very  little 
or  no  evidence  of  internal  lesion  aside  from  the  mental 
disorder.  The  form  of  insanity  which  occurs  to  the 
melancholiac  is  that  which  is  most  likely  to  come 
before  the  Examiner.  There  is  usually  deficient  en- 
ergy of  digestion,  with  costiveness  and  constipation ; 
pale  and  abundant,  or  scanty  urine  loaded  with  lithates; 
pulse,  soft  and  compressible ;  skin,  sallow,  hard  and 
dry,  or  sometimes  cool  and  clammy.  "  The  com- 
plexion of  the  insane  person  is  never  clear  and  healthy." 
Fixed  dull  pain  may  be  complained  of  in  the  head,  or, 
at  least,  a  sense  of  oppression.  There  are  impassive, 
immobile  features,  with  a  moody  or  saddened  expres- 
sion. "  The  eyes  are  motionless,  or  directed  towards 
the  earth  or  some  distant  point ;  and  the  look  is 
askance,  uneasy  and  suspicious."  In  the  more  dis- 
tinctly nervous  temperament  there  is,  as  would  be  ex- 
pected, a  more  changeful  countenance,  and  a  greater 
activity  of  movement.  There  is  loquacity,  and  varied 
emotions  lend  vivacity  to  the  features;  the  eye  is  quick 
and  flashing  ;  the  skin  dry,  and  more  florid  in  parts, 
with  unnatural  pallor  in  others  ;  the  pulse  is  rapid,  but 
feeble  and  jerking.  There  are  derangements  of  the 
secretions.,  irregular  and  capricious  appetite,  and  ten- 
dency to  emaciation.  Indeed,  defective  nutrition  is 
so  large  an  element  in  the  etiology  of  insanity,  that 
some  high  authorities  attribute  to  it  the  whole  disease. 
All  diseases  which  notably  impair  the  constitution  of 


the  blood  may  awaken,  or  exaggerate,  the  hereditary  - 
or  acquired  predisposition.  Unfortunately  the  con- 
verse is  not  always  true  :  insanity  once  existent,  with 
evident  poor  bodily  health,  is  not  always  removed  when 
health  seems  thoroughly  restored.  The  worst  cases,' 
notoriously,  are  those  which  manifest  mental  derange- 
ment with  ragh  health.  Briefly:  In  making  up  an 
opinion  in  a  suspected  case,  in  addition  to  the  family 
history,  the  habits  of  eating,  drinking,  sleeping,  and 
occupation;  the  diseases  previously  existent ;  the  exact 
present  condition  of  the  digestive  and  cerebral  organs; 
the  peculiarities  in  surroundings,  dress,  bearing,  and 
expression,  as  contrasted  with  the  antecedent  usage; 
and,  finally,  the  general  physiognomy  of  the  case  are 
each  to  be  fully  investigated.  In  the  absence  of  glar- 
ing evidences  of  eccentricities,  or  peculiarities,  as  com- 
pared with  those  which  sane  people  may  exhibit,  the 
individual  must  be  compared,  or  contrasted  with  his 
previous  self,  and  then  the  change,  if  any,  be  traced  to 
its  real  cause. 

SPINAL  DISEASES. — Spinal  Inflammation  of  the  chronic 
form,  whether  of  the  meninges  or  substance,  is  an 
insuperable  obstacle  to  insurance.  The  comparatively 
light  local  symptoms  frequently  cause  it  to  be  con- 
founded with  rheumatism  or  neuralgia,  but  careful 
examination  will  ordinarily  elicit  the  presence  of  a 
much  greater  general  disorder  than  would  occur  in  such 
cases. 

There  is  generally  a  fixed  pain,  usually  high  up  on 
the  vertebra,  slight  tenderness  on  percussion  or  deep 
pressure ;  the  pain  aggravated  by  movement,  especially 


if  quick.  The  passage  of  a  hot  sponge  ov^r  the  part 
is  also  likely  to  give  increased  pain.  Tnere  is  a  liabil- 
ity to  spasms  or  paralysis,  particularly  of  tne  muscles 
of  the  neck  and  back,  upon  the  occurrence  of  exciting 
causes. 

The  occurrence  of  curvature  witn  tnese  evidences  of 
local  lesion,  adds  to  the  certainty  of  diagnosis. 

Spinal  Irritation,  or  that  ill-defined  assemblage  of 
hyperaesthesia,  nervous  excitability,  with  disturb- 
ances of  remote  organs,  whatever  its  real  pathology,  is 
usually  accompanied  by  such  evidences  of  digestive, 
thoracic,  or  cerebral  disorder,  that  tney  aione  suffice 
for  rejection  without  differential  diagnosis. 

PARALYSIS,  of  whatever  degree,  wnether  dependent 
on  Morbid  Nutrition,  Degeneration,  Tumors, 
Apoplexy,  Traumatic  Lesion,  or  Softening,  always 
disqualifies. 

The  trouble  in  diagnosis  here,  is  mainly  due  to  the 
imagination  of  the  patient.  Without  actual  paralysis, 
either  of  motion  or  sensation,  there  is  often  Deficient 
Innervation.  There  is  a  sense  of  weakness  of  the  knees, 
with  slight  numbness  or  prickling  sensation  ;  a  loss  of 
perfection  of  the  muscular  sense ;  disturbance  of  the 
function  of  the  organs  of  the  trunk  on  tne  ,evel  of 
the  lesion  —  thus  disturbed  respiration  and  circulation, 
disturbed  digestion,  slow  and  imperfect  extrusion  ot 
the  faeces  and  urine.  The  genital  system  is  depressed 
in  activity ;  the  muscular  tissue  wastes,  and  nutrition 
generally  is  imperfect.  The  brain  sympathizes  more 
or  less,  and  spasmodic  contraction  may  alternate  with 
the  paralysis  or  deficient  power  of  motion. 


143 

The  history  of  the  case  will  here  throw  light  upon 
the  symptoms  present.  A  blow,  a  wrench,  a  concus- 
sion ;  exposure  to  cold  and  moisture ;  excessive  fa- 
tigue, long  continued  cramped  positions  incident  to 
various  occupations,  certain  morbid  habits  and  indul- 
gences, mineral  poisons,  hereditary  predispositions, 
and  cachexia,  severally,  may  be  identified  as  originating 
the  difficulty.  On  the  other  hand,  hypochondria  and 
hysteria  may  imitate  the  symptoms  very  closely. 
There  is  a  large  amount  of  vulgar  literature  afloat 
which  serves  to  torture  young  adults,  especially,  with 
the  idea  that  the  dreaded  tabes  dorsalis  has  already 
seized  upon  them.  Half  of  the  symptoms  in  these 
cases  depend  upon  dyspepsia,  and  two-thirds  of  the 
balance  upon  the  imagination  of  the  victims. 

VII. 

Miscellaneous  Affections, — Psoas  and  lumbar  abscesses 
while  present  reject;  and  even  when  recovery  seems 
perfect,  from  their  great  tendency  to  return,  throw 
doubt  on  the  propriety  of  accepting  the  applicant. 
All  abscesses  of  any  considerable  extent  postpone.  Re- 
current abscesses  involve  suspicion  of  some  cachexia. 
Even  furunculi  should  not  lightly  be  passed  over,  and 
carbuncle^  reject. 

Open  ulcers  and  obstinate  cutaneous  affections  are  so 
generally  connected  with  constitutional  taint,  or  per- 
manen*  lesion  of  nutrition,  that  the  case  is  rendered 
doubtful  by  their  presence. 

Large  or  extensive  varicose  veins,  chronic  and  numer- 
ous enlargements  or  induration  of  the  lymphatic  glands, 


144 

fistula  (p.  22,  et  seq.},  morbus  coxarius,  or  acute  or 
chronic  inflammation  within,  or  about  any  of  the  larger 
joints. 

Irreducible  hernia,  double  hernia. 

Excessive  loss  of  structure,  as  amputations  above  the 
middle  third  of  the  thigh,  or  at  the  shoulder  joint. 

Tumors  of  a  non-malignant  character,  but  involving 
danger  by  their  anatomical  position,  or  as  requiring  a 
severe  surgical  operation. 

All  tumors  or  growths  of  a  malignant  or  scrofulous 
nature ;  Exostoses,  Enchondroma,  etc. 

Loss  of  sight  or  hearing  from  accident  or  causes 
not  involving  disease  of  the  cerebral  centres,  never- 
theless impair  the  risk,  as  subjecting  the  unfortunate 
subject  unduly  to  injuries  which  the  deprivation  of  the 
special  sense  does  not  permit  him  to  avoid, 

Finally,  diseases  which  may  have  been  present,  but 
from  which  there  seems  to  have  been  perfect  recovery, 
not  infrequently  leave  discoverable  effects  and  influ- 
ences to  the  educated  eye,  which  materially  lessen  the 
life  expectation. 

VIII. 

Female  Applicants. —  Although  some  companies 
decline  all  female  risks,  it  is  safe  to  say  that,  taken 
together,  they  are  equally  eligible  as  those  of  males. 
As  before  remarked,  even  the  child-bearing  period 
does  not  bring  to  them  a  mortality,  materially  prepon- 
derant over  that  of  males  of  similar  age.  Indeed,  if 
anything,  the  exposures  and  vicissitudes  to  which 
males  are  ordinarilv  subjected,  during  the  active  years 


145 

of  adult  life,  more  than  balance,  in  fatal  results,  the 
incidents  of  the  female  life  during  this  period. 

Certain  anatomical  differences  with  regard  to  the 
height,  weight,  chest  measurement,  and  capacity,  have 
previously  been  noted,  (p.  54.) 

There  is,  numerically,  a  greater  proportion  of  ner- 
vous temperaments,  and  the  modes  of  life  more  fre- 
quently expose  to  the  evils  of  deficient  ventilation  and 
sedentary  habits.  But  to  these  their  systems  become 
accustomed,  by  well  known  physiological  law,  so  that 
not  as  deleterious  results  are  produced  as  would  be  in 
the  male. 

The  regularity  and  perfection  of  the  menstrual  func- 
tion is  to  be  ascertained ;  it  being  remembered  that 
individual  peculiarities  in  this  respect  are  to  be  weighed 
rather  in  their  relation  to  the  general  health  than  with 
reference  to  exact  rules.  If  there  is  good  health  oth- 
erwise, irregularities  in  the  menstrual  function  scarcely 
impair  the  risk.  But  at  the  climacteric  period,  the 
difficulties  incident  to  the  cessation  of  the  function 
must  be  carefully  inquired  after.  This  is  an  objec- 
tionable time  to  insure ;  but  in  the  absence  of  notable 
disturbance  of  the  general  health,  or  evidences  of  local 
disease,  the  party  need  not  be  declined.  An  anaemic 
or  chlorotic  condition,  or  signs  of  the  cancerous  cachexia 
will  exclude. 

Primary  gestation  impairs  the  risk,  ,but,  if  this 
proceed  without  difficulty  or  danger  to  its  termination, 
subsequent  pregnancy  need  not  be  considered  as  add- 
ing to  the  risk.  Statistics  are  said  to  show  that  the 
mortality  from  first  labors,  and  ensuing  puerperal 
10 


I46 

fever,  is  about  twice  that  of  all  ensuing  labors  up  to 
the  ninth  ;  after  the  ninth,  the  danger  is  increased 
with  each  succeeding  pregnancy  and  parturition. 
Whether  this  proportion  is  closely  approximated  or 
not,  there  is  no  doubt  of  the  general  truth  of  the 
proposition. 

Labors  requiring  instrumental  assistance,  miscar- 
riages, or  repeated  mal-presentations,  or  haemorrhage, 
impair  or  exclude  the  risk.  The  occurrence  of  Puerperal 
Fever,  or  Mania,  also  declines.  Remarkable  varicosity 
of  the  veins,  phlegmasia  dolens^  dropsical  effusions,  etc., 
are  equally  objectionable.  Vesico-vaginal,  or  rectal 
fistulae,  or  lacerations,  also,  while  present,  exclude. 
Emaciation  and  exhaustion,  during  lactation,  also 
militate  against  assurance.  Chronic  Metritis  or  Sub- 
involution,  deep  ulcerations  and  profuse  leucorrhceal 
or  purulent  discharges,  at  least,  postpone. 

But  it  should  be  recollected  that  mere  dyspeptic 
derangements,  or  the  habit  of  the  parts,  may  keep  up 
apparent  symptoms  when  important  organic  disease 
has  passed  away.  The  real  condition  of  the  general 
health  is  here  the  point  to  be  investigated. 

It  is  unnecessary  to  remark,  to  the  experienced  prac- 
titioner, that  organic  uterine  disease  is  vastly  less  fre- 
quent and  important  than  is  claimed  by  the  specialists. 
The  symptoms  paraded  as  proving  its  existence,  in 
the  large  majority  of  instances,  being  due  to  totally 
different  causes.  Even  if  it  would  be  permitted,  it  is 
doubtful  whether,  so  far  as  insurance  is  concerned, 
specular  or  digital  examination  would  give  any  valua- 
ble information  aside  from  that  which  can  be  gathered 


H7 

from  the  history  and  the  general  symptoms  presented. 
Cases  which  suggest  such  examination  to  the  family 
physician,  so  frequently  have  concurrent  evidences  of 
disease,  that  differential  diagnosis  becomes  unnecessary, 
for  these  alone  decline. 

The  facts  with  regard  to  the  transmissibility  of 
hereditary  diseases,  insanity,  etc.,  in  certain  instances, 
rather  to  the  females  than  to  the  males  of  the  family, 
and  vice  versa,  may  have  weight  in  deciding  upon  the 
risk.  (p.  126.) 

IX. 

General  Character  of  the  Risk.— The  systematic 

survey  which  has  been  taken  of  the  history  of  the 
applicant,  and  the  present  condition  of  the  individual 
organs  and  functions  of  the  body,  is  merely  prepara- 
tory to  answering  the  all  important  question  pro- 
pounded by  the  Insurance  Company :  "  Do  you 
RECOMMEND  THE  RISK  ?"  This  question  should  be 
answered  definitely  and  distinctly — YES,  or  No. 

But,  before  answering  it,  there  are  certain  general 
considerations  which  it  is  necessary  to  have  fully  in 
mind.  These  are  derived  from  the  general  physiognomy 
of  the  case  as  indicating  the  CONSTITUTION.  Unde 
this  somewhat  indefinite  designation  we  refer  to  the 
Temperament,  the  Diathesis,  or  the  Cachexia  of  the 
party. 

The  Temperament  has  already  been  referred  to,  (p.  61 
et  seq.)  Here  the  question  arises  :  Is  the  party  so 
situated  that  his  peculiar  temperament  modifies  the 
character  of  the  risk  ?  And  in  answering  this,  the 


I48 

same  principles  of  prognosis  are  involved  as  in  weighing 
its  relation  to  present  acute  disease. 

The  Diathesis  bears  the  same  relation  to  disease  that 
the  temperament  does  to  health.  Original  or  acquired 
abnormalities  in  the  organs  determine,  on  the  occur 
rence  of  any  special  disease,  a  modification  in  its  course 
or  tendencies,  which  assimilates  its  changes  and  symp- 
toms to  those  which  are  especially  peculiar  to  the 
diathetic  infirmity.  In  the  absence  of  exciting  cause 
the  diathesis  may  be  apparently  latent.  In  the  absence 
of  direct  manifestation  it  may  sometimes  be  cogently 
inferred  from  the  family  or  personal  history,  or  from 
the  obvious  results  of  previous  disease.  Each  im- 
presses its  own  physiognomy.  Among  those  diatheses 
prominently  demanding  study,  may  be  mentioned  the 
Strumous,  ultimating  in  scrofulosis,  or  tuberculosis,  and 
characterized  by  defective  nutrition,  imperfect  assimi- 
lation with  consequent  impaired  function  of  the  organs, 
with  slow  and  deficient  reparative  power. 

The  Gouty  or  Rheumatic  diathesis,  characterized  by 
"  a  predisposition  to  the  undue  formation  of  uric  acid, 
and  to  congestion,  irritation  or  inflammation  of  the 
muscular  and  sero-fibrous  tissues,  of  the  vascular  sys- 
tem, of  the  serous  membranes,  and  of  the  perito- 
neum." The  development  of,  on  the  one  hand,  gouty 
affections,  and  on  the  other,  rheumatic  disorders,  seems 
to  be  due  to  the  relative  conditions  of  the  skin,  and 
digestive  mucous  membrane. 

The  Adipose  diathesis  is  marked  by  its  results. 
Ordinarily  there  is  deficient  digestive  energy  and  mus- 
cular weakness  The  viscera  are  large,  but  notably 
inactive 


The  Phlogistic,  usually  engrafted  upon  the  Sanguine 
Temperament,  where  acute  inflammation,  with  active 
symptoms,  readily  supervenes  upon  slight  causes. 
Here  there  is  generally  great  activity  of  the  blood 
making  processes,  with  some  imperfection  of  structure 
of  the  excreting  organs. 

The  Typhoid,  when  with  rapidity  of  textural  changes, 
easily  exaggerated  by  disturbing  influences,  there  is 
feebleness  of  nutrition  and  repair  with  inactivity  of 
the  excretories. 

In  fine,  the  acute  physician  may  recognize  a  great 
number  of  these  general  proclivities  to  disease,  yet 
each  consistent  with  present  health,  which,  being 
known,  must  enter  into  his  well  compacted  decision 
as  to  the  real  character  of  the  risk. 

The  Cachexia,  unlike  the  Temperament  or  Diathe- 
sis, determines  the  presence  of  disease, —  not,  perhaps, 
involving  any  particular  organ,  but  pervading,  in  its 
malign  influence,  each  and  all.  It  may  be  the  diathesis 
developed  into  an  existent  disease.  The  diathesis, 
being  known,  may  never  find  development  into  ca- 
chexia  or  local  disease,  being  prevented  by  appropriate 
hygienic  influences.  But  the  cachexia  may  originate 
without  the  previous  existence  of  the  diathesis,  and, 
in  this  case,  is  usually  more  amenable  to  therapeutics. 
When  both  co-exist,  the  prognosis  is  thereby  rendered 
vastly  more  grave  than  it  would  be  even  with  greater 
severity  of  local  symptoms. 

The  noticeable  cachexiae  are  those  connected  with  the 
developed  diathesis,  as  above  suggested,  and  to  these 
may  be  added,  as  requiring  attention,  the  Syphilitic, 


150 

Erysipelatous,  Anaemic  or  Chlorotic,  Albuminoid, 
Haemic,  Haemorrhagic,  Rachitic,  Cancerous,  etc. 

The  sum  total,  so  to  speak,  of  the  power  of  carry- 
ing on  the  processes  of  life,  ministering  to  repair,  and 
resisting  morbific  influences,  derived  by  the  system  as 
a  whole,  is  expressed  by  the  term  the  CONSTITUTION, 
This  word  is  significant  of  the  Vital  Force,  or  indi- 
vidual capacity  for  living.  It  measures,  for  the  Exam- 
iner, the  Life-Expectation.  Deviations  from  the 
typical  standard  of  formation  and  action,  as  arbitrarily 
established  for  purposes  of  scientific  comparison,  may 
be  found  present  to  an  indefinite  extent,  and  yet  the 
capacity  for  living  be  fully  equal  to,  or  even  above  the 
Insurance  Average. 

Poetical  descriptions,  or  ideas,  of  the  mem  sana  in 
corpore  sano,  may  differ  as  widely  as  men  themselves, 
and  it  is  idle  to  set  up  either  Apollo  or  Vulcan  as  types 
of  Methuselah.  Nay,  the  educated  intellect,  by 
adapting  the  frail  body  appropriately  to  its  surround- 
ings, may  cause  its  years  to  surpass  those  of  the  most 
symmetrical  and  well  developed  athlete. 


APPENDIX. 


Note  to  page  15,  (Occupation,) 

Occupation  has,  of  course,  a  more  or  less  direct  bearing  on  health 
and  longevity :  in  some  vocations  there  is  constant  danger  of  accident 
or  violent  death  even,  while  in  others  the  danger  on  this  account  is 
so  slight  as  to  be  quite  unworthy  of  consideration  at  all.  Again,  a 
particular  calling  may  involve  not  the  least  risk  on  account  of  phys- 
ical danger,  and  yet  be  extremely  prejudicial  to  health  and  longevity. 
The  following  table  indicates  approximately  the  relative  influence  of 
the  various  callings  and  professions  on  the  duration  of  life;  Class  I 
being  considered  most  dangerous,  Class  IV  least  so : 


CLASS  I. 


Brakeman  on  Freight  Trains. 
Buzz  Sawyer. 
Circular  Sawyer. 


Powder  Maker. 
Seaman. 


CLASS  II. 


Bridge  Builder. 

Boatman. 

Barber  on  Steamboat. 

Brakeman  on  Mail  Traini. 

Cartridge  Maker, 

Clerk  on  River  Steamboat. 

Captain  of  Lake  or  Sea  Vessel 

Car  Coupler. 

Conductor  on  Freight  Trains. 

Cooper. 

Dock  Laborer. 

Engineer  on  River  Steamer. 

Farrier. 

Fireworks,  Maker  of. 

Fireman  (Locomotive). 

Grinder  of  Edged  Tools. 

Horse  Shoer. 

Laborer,  (Wharf,  Warehouse,  Grain  Elevator.) 

Lighterman. 

Lumberman. 

Master  or  Mate  of  Vessel. 

Match  Maker. 


Mail  Agent,  (Traveling). 

Mate  of  Riter  Steamer. 

Miner  (underground). 

Nightman. 

Pilot. 

Quarrier. 

Quarryman. 

Raftsman. 

Railroad  Engineer. 

Race  Horseman. 

Sailor. 

Steward  on  Steamboat. 

Switchman. 

Stevedore. 

Slater. 

Steel  Polisher. 

Telegraph  Builder. 

Timber  Cutter. 

Train  Starter. 

Wood  Carver  and  Turn«r 

Yard  Master. 


I  {2 


CLASS  III. 


Agricultural  Implement  Maker. 

Bar  Keeper. 

Blacksmith  (working). 

Blast  Furnace  (working  in). 

Block,  Oar  and  Mast  Maker 

Boiler  Maker. 

Bolt  Maker. 

Brass  Founder  (working). 

Bricklayer. 

Broker  in  Cattle  and  Hone*. 

Baggage  Master  on  Trains. 

Baggage  Master  at  Station. 

Canal  Boatman. 

Captain  on  River  Steamer. 

Car  Driver. 

Carman  (Drayman). 

Carpenter  and  Joiner. 

Caulker  (Ship). 

Coachman. 

Cork  Cutter. 

Cooper. 

Coal  Heaver. 

Carpenter  (Railroad). 

Chief  Engineer. 

Car  Repairer. 

Car  Cleaner. 

Conductor  on  Passenger  Train*. 

Distiller. 

Driver  of  Express  Wagon. 

Drover. 

Detective  (Railroad). 

Express  Agent  (not  on  trains). 

Express  Agent  on  trains. 

Engineer  on  Stationary  Engine. 

Express  Messenger  on  Trains. 

Foundry  (employee  in). 

Fireman  (Engine,  Hose,  Hook  and  Ladder). 

Freight  Agent  (station). 

Freight  Laborer. 

Hod  Carrier. 

Horse  Breaker. 

Hostler. 


Inspector  of  Wood  and  Timber. 

Knife  and  Instrument  Maker. 

Lead  Pipe  and  Tube  Maker. 

Lighthouse  or  Lightship  Keeper. 

Lightning  Rods  (one  who  puts  up). 

Livery  Stable  Keeper. 

Lumberman,  manufacturer. 

Laborer,  common. 

Locomotive  Superintendent. 

Limestone  Quarrier  or  Burner. 

Master  Mechanic. 

Mason. 

Machinist. 

Metal  Turner. 

Miner  (surface). 

Naval  Architect. 

Operative  in  Saw  and  Planing  MilU. 

Painter. 

Prison  Office  Keeper. 

Puddler. 

Rolling  Mills 

Saw  Mill  (employee). 

Shooting  Gallery  Keeper. 

Scythe  and  Sickle  Maker. 

Ship  Carpenter. 

Shipsmith. 

Slate  Quarrier. 

Stable  Keeper. 

Stage  Driver. 

Sugar  Refinery  (workman  in) 

Station  man. 

Signal  man. 

Ship  Inspector. 

Stone  Cutter  and  Dresser. 

Track  Laborer. 

Track  Superintendent. 

Track  Foreman. 

Track  Inspector. 

Teamster. 

Turpentine  Manufacturer. 

Watchman. 

Wood  Chopper. 


CLASS  IV. 


Actor,  Actress. 

Ale  or  Beer  Manufacturer. 

Apothecary,  Druggist. 

Architect. 

Armorer. 

Artificial  Limb  Maker. 

Actuary. 

Artist,  Painter. 

Attorney,  Lawyer. 

Auditor. 

Army  or  Navy  Officer  (not  in  service). 

Author,  Writer. 

Bookseller. 

Broker  in  mdse.,  stocks,  or  (old. 

Bank  Officer  or  Clerk. 

Book-keeper,  Accountant. 

Baker. 

Barber. 

Basket-maker. 

Bell-hanger. 

Boat  Builder. 

Bookbinder. 

Boot  and  Shoe  Maker. 

Box  and  Trunk  Maker. 

Brass  Polisher,  Finisher. 

Brewer. 

Brickrraker. 

Builder,  not  Laborer 

Cabinet  Maker. 


Cap  or  Carpet-bag  Maker. 

Carpet  Weaver. 

Chair  Maker. 

Chemist  and  Druggist. 

Chiropodist. 

CHI  Engineer. 

Clock  Maker. 

Coach  Maker. 

Coffee-Housc  Keeper. 

Commercial  Agent. 

Clergyman.  Minister. 

Clerk,  (generally). 

Clothierf 

Commission  Merchant. 

Captain  of  lake  or  sea  gteame 

Chemist,  manufacturing. 

Coal  Miner  (underground). 

Confectioner. 

Cook  (professional). 

Coppersmith 

Copperplate  Printer. 

Cornice  Moulder. 

Cotton  Dyer. 

Cotton  Packer  and  Presser. 

Cotton  Printer. 

Cow-keeper,  Milk  Seller. 

Currier 

Cujtoi-  house  Officer. 

cu*. 


1S3 


CLASS    IV—  Concluded. 


Draughtsman. 

Dressmaker. 

Dentist. 

Die  Engraver,  Mould  Maker. 

Drug  Grinder. 

Eating -House  Keeper. 

Embosser. 

Embroiderer. 

Engraver. 

Editor,  Reporter. 

Engineer,  Mining. 

Fisherman. 

Farmer,  owner, 

Farm  Laborer. 

File  Maker. 

Fish  Curer. 

Fish  and  Oyster  Dealer. 

Furrier. 

Gardener. 

Gas  Fitter. 

Gas  Works,  service, 

Gauger. 

General  Trader,  (traveling). 

Glazier. 

Glover. 

Gold  Boater. 

Glass  Blower. 

Gold  or  Silver  Refiner  and  Worker. 

Grocer  (general). 

Grain  Measurer. 

General  Trader,  storekeeper. 

Grave  Digger,  Sexton. 

Gunsmith. 

Harness  Maker,  Saddler. 

Hat  and  Cap  Maker. 

Hollow  Ware  Maker. 

Hoop  Maker. 

Hoop  Skirt  Maker. 

Hotel  or  Tavern  Keeper  (country). 

House  Decorator. 

Huckster. 

Hotel  Keeper,  proprietor. 

Insurance  Officer  and  Clerkf  (not  traveling). 

Ivory  Cutter  and  Worker. 

India  Rubber  Manufactory,  employee  in. 

Ink  Maker. 

Instrument  Case  Maker. 

Japanner. 

Jeweler,  worker. 

Lithographer  (not  working). 

Leather  Dyer. 

Locksmith. 

Looking  Glass  Maker. 

Last  Maker. 

Machinist,  not  in  employ  of  railroad* 

Marble  Cutter. 

Marble  Mason. 

Market  man. 

Medical  Student. 

Metal  Refiner. 

Miller,  grain  and  flour. 

Morocco  Dresser. 

Millwright. 

Manufacturer  (not  working). 

Milliner. 

Musician. 

Moulder. 

Naval  Officer,  in  service. 

Nail  Maker. 

Nurseryman,  working. 

Oil  Dealer,  petroleum. 

Operative  in  Cotton  or  Woolen  Mill*. 

Organ  Builder. 

Ouster  Dealer. 

Phonographer. 


Photographer. 

Physician. 

Postmaster. 

P.  O.  Clerk  (not  traveling) 

Packer  of  Hay,  Cotton,  Pork,  Beef. 

Packing  Case  Maker  (not  using  circular  saw). 

Painter,  house,  ornamental. 

Paper  Hanger. 

Paper  Box  Maker. 

Pastry  Cook. 

Pawnbroker. 

Pencil  Maker. 

Picture^frame  Maker. 

Percussion  Cap  Maker. 

Plasterer. 

Plater. 

Plumber. 

Porter. 

Potter. 

Pressman. 

Printer,  compositor. 

Pump  Maker, 

President  or  Secretary  of  Corporation 

Publisher. 

Purser,  steamship. 

Policeman. 

Railroad  Employees. 

Rectifier. 

Rope  Maker. 

Surgeon. 

Ship  Rigger. 

Soap  Boiler. 

Sail  Maker. 

Saloon  Keeper. 

Sausage  Maker. 

Segar  Maker, 

Scourer,  Dyer. 

Ship  Broker,  agent. 

Ship  Builder,  contractor. 

Steward  on  vessel  or  steamer. 

Smelter. 

Soda  Water  Manufacturer. 

Shovel  Maker. 

Silversmith. 

Spindle  Maker. 

Spring  Maker. 

Steel  Pen  Maker. 

Stereotyper. 

Surgical  Instrument  Maker. 

Surveyor. 

Tanner. 

Tinman,  tinker. 

Traveling  Agent. 

Type  Founder. 

Tailor. 

Teacher. 

Telegraph  Operator. 

Tool  Maker. 

Turner,  Wood  and  Ivory 

Umbrella  Maker. 

Upholsterer. 

Varnish  Maker. 

Vitriol  Manufacturer. 

Watchmaker. 

Weighing  Machine,   Scale  Maker. 

Wharfinger. 

Wheelwright. 

Whip  Maker. 

Whitesmith. 

Wig  Maker. 

Wire  Maker. 

Wood  Dealer 

Watchman. 

Weaver. 

Weigher. 


Note  to  page  16, 

The  popular  idea  that  the  affection  known  as  "  clergyman's  sore 
throat "  predisposes  to  consumption  is,  to  a  great  extent,  erroneous. 
On  the  other  hand,  it  is  probably  safe  to  say  that  consumption  finds 
fewer  victims  among  the  clergy,  than  among  any  other  class  of 
people — the  exercise  of  public  speaking  tending  rather  to  develope 
and  strengthen  the  lungs  than  otherwise.  As  a  general  rule,  public 
speakers  are  safe  and  desirable  risks. 

Note  to  page  16,  (Professional  men, ) 

It  must  be  admitted,  as  an  exception  to  the  general  rule,  that 
under-teachers  in  city  schools  are  most  unfavorably  situated  as  regards 
health  and  longevity.  Confined  for  six  or  eight  hours  a  day  in  close, 
ill-ventilated  rooms,  which  are  crowded  with  children  in  all  stages  of 
uncleanliness  ;  with  both  body  and  mind  wrought  up  to  the  highest 
pitch  of  exertion,  and  all  this  for  many  consecutive  weeks  or  even 
months,  it  is  scarcely  to  be  wondered  at  that  their  standard  of  health 
is  low  as  compared  with  that  of  the  great  majority  of  teachers  in  the 
colleges  and  higher  schools,  or  of  teachers  in  common  schools  in 
country  towns. 

It  is  probable  that  statistics  would  show  a  marked  difference  in 
the  average  duration  of  life,  between  city  and  country  physicians, 
and  that  the  difference  would  be  in  favor  of  the  former.  The 
terribly  exhausting  life  of  the  country  practitioner,  together  with  his 
unavoidable  irregularity  of  habits  and  of  hours  of  rest,  cannot  be 
otherwise  than  unfavorable  to  long  life. 

As  regards  other  professions,  it  does  not  appear  that  any  marked 
difference  obtains  between  city  and  country.  But  the  popular  belief, 
that  the  opportunities  for  the  enjoyment  of  vigorous  health,  are,  on 
the  whole,  better  in  the  country  than  in  the  city,  is  probably  true, 
though  a  series  of  observations  on  this  point  are  much  needed.  The 
actual  difference,  however,  is  not  so  great  as  has  been  supposed  ;  owing 
perhaps  to  the  increasing  popularity  of  gymnastic  and  other  exercises 
intended  to  develop  a  high  state  of  physical  health  ;  the  improved 
methods  of  constructing  dwelling  houses  as  regards  warming  and  ven- 
tilation, and  the  improved  notions  of  society  as  regards  diet  and 


'55 

dress  j  fashionable  society  having  now  learned  to  tolerate  warm  attire, 
however  ridiculous  or  preposterous  its  form  may  be — another  reason 
for  the  improved  hygienic  condition  of  cities  is,  that  modern  science 
has  at  length  developed  the  fact  that  contagious  and  zymotic  diseases 
may  be,  to  a  great  extent,  prevented  by  the  enforcement  of  sanitary 
regulations  ;  consequently  every  city  of  any  considerable  size  has  its 
"  Board  of  Health,"  clothed  with  ample  powers,  and  held  rigidly 
accountable  for  their  employment,  both  by  public  opinion,  and  by  an 
exacting  and  critical  newspaper  press. 

Note  to  page  19.  (Table  of  Mortality,) 

In  the  first  of  the  annexed  tables,  is  shown  the  mortality  from  all 
diseases  usually  mentioned  in  Life  Insurance  Applications,  for  the 
year  1860,  together  with  the  rates  they  severally  bear  to  10,000 
deaths,  from  all  known  causes  of  mortality.  The  second  table  shows 
the  proportion  of  deaths  to  10,000  from  all  causes,  in  the  several 
"census  districts"  of  the  United  States,  from  the  same  diseases,  and 
for  the  same  year.  The  States  arid  Territories  comprising  the  several 
districts  will  be  found  in  connection  with  the  table  on  page  16.  It 
will  be  observed  that  the  deaths  from  "colic,"  "palpitation"  and 
"spitting  of  blood  "  are  not  given  ;  this  is  simply  because  they  are 
very  properly  regarded  as  being  symptoms  only  ;  and  therefore  entitled 
to  no  place  in  a  classified  arrangement  of  diseases  for  scientific 
purposes.  (Compiled  from  the  Census  Report  for  1860). 

As  Life  Insurance  Companies  have  multiplied,  and  operations  on  a 
more  extended  scale  have  been  made,  tables  of  mortality  have  also 
multiplied. 

The  Carlisle  table  is  given  on  page  7,  of  this  work ;  below  will 
be  found  the  "  American,"  "  Combined  Experience  "  and  "  English'' 
tables  —  the  latter  being  that  generally  known  as  "  Farr's  table." 


156 


SHOWING  THE  DEATHS  IN  THE  UNITED  STATES,  AND  THE  RATIO 
TO  10,000  DEATHS,  FROM  DISEASES  USUALLY  MENTIONED  IN 
LIFE  INSURANCE  APPLICATIONS,  FOR  THE  YEAR  1860. 


DISEASE. 

NO.  OF  DEATHS. 

NO.  TO  10,000 
FROM  ALL  KNOWN 
CAUSES. 

DISEASE. 

NO.  OF  DEATHS. 

NO.  TO  IO,OOO 
FROM  ALL  KNOWN 
CAUSES. 

3,083 
669 
1,919 
3,292 
49,082 

44 
1,663 
6,C3° 
12,090 
501 
37 
4i 
931 

86 

18 
53 
92 
i,379 
I 
46 
183 
355 
J4 
i 
i 
26 

452 
385 
2,633 

4<637 

12 
IO 

73 
130 

Asthma  .  

Influenza                  ........ 

Bronchitis 

Consumption 

Palpitation         ..... 

Colic  

Quinsy  

730 
1,881 
360 
26,402 

20 
52 
IO 
741 

Diphtheria 

Rheumatism                -   

Disease  of  the  Heart 

Dropsy 

Scarlet  Fever  

Fits  (Epileptic) 

Spitting  of  Blood 

Fistula  

Disease  of  Urinary  Organs. 
Syphilis  .  . 

2,112 
233 

1 

Gout  . 

Intemperance  _  

SHOWING  THE  PROPORTION  OF  DEATHS  TO  IO,OOO  FROM  ALL  CAUSES, 
IN  THE  "CENSUS  DISTRICTS"  FOR  THE  YEAR  1860. 


DISTRICTS. 

PROPORTION   TO    10,000   OF   ALL   DEATHS. 


I. 

II. 

III. 

IV. 

V. 

VI. 

VII. 

VIII. 

IX. 

109 
17 
3i 
140 
2,162 

84 
16 
18 
81 
i,535 

141 
25 
"5 
107 
1,793 

62 

3 

79 
1,298 

7f 
26 

60 

95 
i,!95 

55 

i 

60 
1,048 

86 
29 
62 
71 
492 

63 

14 

48 

50 

563 

no 
37 
51 
47 
1,214 

Bronchitis 

Consumption  . 

Colic 

Diphtheria  

47 
319 
3M 
17 

ii 

22 

| 

3S 

3° 
126 

258 
i4 

81 

164 

5°l 

35 
95 
3H 

12 

20 
96 
601 

12 

52 
83 

329 
7 

i 

116 
215 
241 

i5 
5 

i 

73 
ii 

7 

102 
92 

Disease  of  the  Heart.. 

Fits  (Kliptic)         

Fistula 

Gout 

Intemperance 

23 
18 

Ii 

177 

22 
9 

7 
107 
75 

22 

16 

4 
74 
194 

15 
7 
6 
74 
103 

39 

'1 

73 
190 

3° 
ii 
7 
61 
88 

29 

8 
J7 
74 
99 

27 
9 
14 
Si 
44 

Insanity 

Influenza                ....  

Liver  Complaint           ... 

Quinsy 

J 

68 
766 

12 

45 
13 
i,°93 

8 

5* 
ii 
1,085 

18 
45 
9 

1,112 

19 
75 

& 

3i 
59 
9 

766 

42 
62 
8 

198 

48 
43 
9 
374 

II 

59 

*9 
965 

Rheumatism  ....  ..  ... 

Rupture 

Disease  of  the  Urinary  Organs 
Syphilis 

82 

7 

55 
51 

57 
3 

52 

3 

60 

4 

49 
5 

54 
ii 

35 
7 

59 

5i 

'57 


RATES  OF  ENGLISH  AND  AMERICAN  MORTALITY. 


—     to 

°u    "* 

K 

jy 

•-   >-. 
Ill 

Zo  J 

1J 

^ 

-  1 

3  ^ 

WJJ 

-•A  j 

M| 

H  '>* 

£ 

e 

W  8. 

**:  ~  **- 

c  J 

VI 

c 

|iB 

c  .2 

"S  w 

3  a  « 

<J        U 

G 

0        U 

(j     rt 

C           £ 

-C  ^-^   O 

& 

i  i 

<  Z- 

IS 

lii 

u    a 
S     a 

13 

I  Hi 

JJ       aj 

<J    W 

-^      rt^ 

S  g  J 

CJ  g'o 

.2  ^  *s 

III 

10 

100,000 

100,000 

749 

676 

48.72 

48.36 

47-05 

II 

99*251 

99,324 

746 

674 

48.08 

47.68 

46.31 

12 

98,505 

98,650 

743 

672 

47-44 

47.01 

45-54 

»3 

97,762 

97,978 

740 

67i 

46.82 

46.33 

44.76 

14 

97,022 

97,3°7 

737 

671 

46.16 

45.64 

43-97 

15 

96,285 

96,636 

735 

67i 

45-5° 

44.96 

43.18 

16 

95,550 

95,965 

732 

672 

44.85 

44.27 

42.40 

17 

94,818 

95,293 

729 

673 

44.19 

4358 

41.64 

18 

94,089 

94,620 

727 

675 

43-53 

42.88 

40.90 

19 

93,362 

93>945 

725 

677 

42.87 

42.19 

40.17 

20 

92,637 

93,268 

723 

680 

42.20 

41.49 

39.48 

21 

91,914 

92,588 

722 

683 

41-53 

40.79 

38.80 

22 

91,192 

91,905 

721 

686 

40.85 

40.09 

38-13 

23 

90,471 

91,219 

720 

690 

40.17 

39-39 

37-46 

24 

89,751 

90,529 

719 

694 

39-49 

38-63 

36-79 

»5 

89,032 

89,835 

698 

38.81 

37.98 

36.12 

26 

88,314 

89-137 

7«8 

703 

38.11 

37.27 

35-44 

27 

87,596 

88,434 

718 

708 

37-43 

36.56 

34-77 

28 

86,878 

87,726 

718 

714 

36.73 

35.86 

34.10 

29 

86,160 

87,012 

719 

720 

3603 

35-*5 

33-43 

30 

85,441 

86,292 

720 

727 

35-33 

34-43 

32.76 

84,721 

85,565 

721 

734 

34-62 

33.72 

32.09 

32 

84,000 

723 

742 

33.92 

33.01 

31.42 

33 

83,277 

84^089 

726 

75° 

33.21 

32.30 

30-74 

34 

82,551 

83,339 

729 

758 

32.50 

31-58 

30.07 

35 

81,822 

82,581 

732 

767 

31.78 

30.87 

29.40 

36 

81,090 

81,814 

737 

776 

31.07 

30.15 

28.73 

37 

80,353 

81,033 

742 

785 

30.35 

29.44 

28.06 

38 

80,253 

749 

795 

29.62 

28.72 

27.39 

39  !         78,862 

79,458 

756 

805 

28.90 

28.00 

26.72 

40 

78,106 

78,653 

765 

815 

28.18 

27.28 

26.06 

41 

77,341 

77,838 

774 

826 

27.45 

26.56 

25-39 

42 

76,567 

77,012 

785 

839 

26.72 

25-84 

24.73 

43 

75,78i 

76,173 

797 

857 

25.99 

25.12 

24.07 

44 

74,985 

75,316 

812 

881    '       25.27 

24.40 

23-41 

45 

74,173 

74,435 

828 

909          24.54 

23.69 

22.76 

46 

73,345 

848 

944 

23.80 

22.97 

22.11 

47 

72,497 

72,582 

870 

981 

33-oS 

22.27 

21.46 

48 

71,627 

71,601 

896 

1,021 

22.36 

21.56 

20.82 

49 

7°,73* 

70,580 

927 

1,063 

21.63 

20.87 

20.17 

5° 

69,804 

69,517 

962 

1,108 

20.91 

20.18 

'9-54 

51 

68,842 

68,409 

1,001 

1,156 

20.20 

19.50 

18.90 

67,841 

67,253 

1,044 

1,207 

19.49 

18.82 

18  28 

I58 


RATES  OF  ENGLISH  AND  AMERICAN  MORTALITY. 


1     C 

V      1 

°n  o 

jj  j    & 

SL  "^ 

JU        . 

5.*! 

£  Lj 

g/a 

rt  W    jj 

•8  .S 

•3.S    ' 

-3  g* 

x    fe 

W   .0 

.£3 

wg 

^^S 

a 

6 

h  '>, 

C 

a. 

X 

—  ^  ^ 

s  s 

|* 

3  S 

.£ 

c.2 
.§  £ 

g   c 

*_ 

11 

<    55 

lii 

11 

<  fc 

J4J 
_il 

ll 

<  w 

^G        t   ."t^ 

u  g*S 

W^   S, 

53 

66,797 

66,046 

i,o9I 

,261 

18.79 

18  16 

17.67 

65,706 

64,785 

1,143 

,316 

18.09 

17.50 

17.06 

55 

64,563 

63,469 

1,199 

,375 

17.40 

16.86 

16.45 

56 

63,364 

62,094 

1,260 

,436 

16.72 

16.22 

15.86 

57 

62,104 

60,658 

J>325 

,497 

16.05 

J5-59 

15.26 

58 

60,779 

59,161 

',394 

,561 

15-39 

14.97 

14.68 

59 

59,385 

57,600 

1,468 

,627 

14-74 

14-37 

14.10 

60 

57,9'7 

55,973 

1,546 

,698 

14.09 

13.77 

13-53 

61 

56,371 

54,275 

1,628 

,77° 

13.47 

13.18 

12.96 

62 

54,743 

1,713 

,844 

12.86 

12.61 

12.41 

63 

53.030 

50,661 

i,  800 

12.26 

12.05 

11.87 

64 

5J,23° 

48,744 

1,889 

1,990 

11.68 

11.51 

11.34 

65 

49,  341 

46,754 

1,980 

2,061 

II.  JO 

10.97 

10.82 

66 

47,361 

44,693 

2,070 

2,128 

10.54 

10.46 

10.32 

67 

45,29! 

42,565 

2,158 

2,191 

10.00 

9.96 

9.83 

68 

43,'33 

4°,  3  74 

2,243 

2,246 

9.48 

9-47 

9.36 

69 

40.890 

38,128 

2,321 

2,291 

8.98 

9.00 

8.90 

7° 

38,569 

35,837 

2,391 

2,327 

8.48 

8-54 

8-45 

71 

36,178 

33,510 

2,448 

2,35' 

8.00 

8.10 

8.03 

72 

33,73° 

3I»I59 

2,487 

2,362 

7-54 

7.67 

7,62 

73 

28,797 

2,5°5 

2,358 

7.10 

7.26 

7.22 

74 

28^738 

26,439 

2,501 

2,339 

6.68 

6.86 

6.85 

75 

26,237 

24,100 

2,476 

2,3°3 

6.28 

6.48 

649 

76 

23,761 

21,797 

2,43* 

2,249 

5.88 

6.  1  1 

6.15 

77 

2i,33° 

19,548 

2,369 

2,179 

5-48 

5.76 

5.82 

78 

18,961 

17,369 

2,291 

,092 

5.10 

5-42 

5-51 

79 

16,670 

2,196 

,987 

4-74 

5.09 

5.21 

80 

'4,474 

13,290 

,091 

,866 

4.38 

4-78 

4-93 

81 

12,383 

11,424 

,964 

,73° 

4.04 

4-48 

4.66 

82 

10,419 

9,694 

,816 

,582 

3-7J 

4-18 

4.41 

83 

8,603 

8,112 

,648 

,427 

3-39 

3.90 

4-17 

84 

6,955 

6,685 

,47° 

,268 

3.08 

3.63 

3-95 

85 

5,485 

5,417 

,292 

,111 

2-77 

3-73 

86 

4,i93 

4,306 

,114 

958 

2.47 

3.10 

3-53 

87 

3,°79 

3,348 

933 

811 

2.19 

2.84 

3-34 

88 

2.146 

2,537 

744 

673 

1.93 

2.59 

3.16 

89 

1,402 

1,864 

555 

545 

1.69 

2.35 

3.00 

90 

847 

385 

427 

1.42 

2.II 

2.84 

91 

462 

'892 

246 

322 

1.19 

1.89 

2.69 

92 

216 

57° 

J37 

231 

98 

J.67 

2-55 

93 

79 

339 

58 

'55 

80 

1.47 

2.41 

94 

21 

184 

18 

95 

64 

1.28 

2.29 

95 

3 

89 

3 

52 

5C 

1.  12 

2.17 

159 


to   26   inclusive,    deduct    the    age    from    100 :    half  the    balance    is    the    expectation 
it  tt     it         tt         gg         tt  tt  it  tt 

tt          tt     tt        tt        *6        ,t 


The  following  simple  rules  for  the  calculation  of  life  expectation 
are  taken  from  the  "Agents  Manual  of  Life  Insurance."  They 
may  be  relied  upon  as  approximately  correct,  and  will  be  found 
useful  in  the  absence  of  the  standard  mortality  tables : 

From   14   to 

"      26   to    30 

"      31    to   40 

"      41    to    <o          "  "          "     "        "        92        "  "  "  " 

'•      51    to    60          "  "          "     "        "        90        "  "  "  " 

Or  deduct  the  age  of  the  party,  whatever  it  ma/  be,  from  80,  and  two-thirds  of  the  difference  Is  the 
average  expectation  :  for  example,  it  the  age  be  43  ;  80 — 43=37  j  %  of  37=24%,  the  average 
expectation,  very  nearly,  as  given  by  the  table. 

The  annexed  table,  after  Quetelet,  shows  the  relative  mortality  of 
the  sexes,  at  different  ages  from  birth  up  to  100  years,  as  affected  by 
city  and  country  life.  The  table  is  constructed  to  exhibit  the  pro- 
portion of  male  deaths  to  one  female  death,  in  both  localities. 

TABLE  SHOWING  THE  RELATIVE  MORTALITY  OF  THE  SEXES  AT 
DIFFERENT  AGES  IN  CITY  AND  COUNTRY.— (AFTER  &UETELET). 


MALE  DEATHS  TO 

[  FEMALE  DEATH. 

Age. 

City. 

Country. 

Still  born            ..            

^•7 

70 

.  11 

17 

.•77 

2, 

,2,Z 

21 

.2,4 

.16 

06 

O7 

06 

•**3 

o  07 

O   0,4. 

O.Q 

O.Q  1 

o.8a 

O  7C 

0,08 

O.Q2 

2A 

III 

26  to  30  years             

OO 

o  86 

10  to  4.0  years 

88 

o  67 

,                     oz 

0  8l 

.07 

i.ii 

0.06 

I.OC 

70  to  80  years         ..... 

O  77 

I  OO 

80  to  100  years.............  •  

o  68 

o  02 

The  comparative  mortality  of  the  white  and  colored  races  is  a 
subject  o/  practical  and  growing  importance  in  its  relations  to  Life 
Insurance.  Already  the  blacks  are  beginning  to  show  an  intelligent 
appreciation  of  the  benefits  of  Life  Insurance,  and  -,he  time  is  not 
far  distant  when  it  will  become  quite  general  among  them.  Full  and 


i6o 


reliable  statistical  infoimation  in  regard  to  the  average  duration  of  life 
among  them  is  not  yet  accessible :  but  the  following  tables,  whereof 
the  first  is  compiled  from  the  Census  Report  of  1860,  and  the  two 
following  from  that  excellent  authority,  Dr.  W.  A.  Hammond,  are 
believed  to  be  reliable,  so  far  as  they  go. 

Table  first,  shows  the  comparative  mortality  of  whites  and  blacks 
in  the  United  States,  from  diseases  alluded  to  in  the  applications  of 
the  various  companies  ;  the  second,  shows  the  comparative  mortality 
of  whites  and  blacks  from  consumption,  at  several  of  the  British  mili- 
tary stations,  as  it  occurs  from  year  to  year  ;  the  third,  shows  the 
comparative  mortality  from  malarial  diseases  at  the  same  stations, 
(Gibraltar  excepted)  from  1818  to  1836  inclusive. 

SHOWING  THE  COMPARATIVE  MORTALITY  OF  WHITES  AND 
BLACKS  IN  THE  UNITED  STATES,  FROM  DISEASES  MENTIONED 
IN  THE  LIFE  INSURANCE  APPLICATIONS,  FOR  THE  YEAR  1850 


NUMBER    OF    DEATHS. 

RATIO   IN     100,000   DEATHS. 

Causes  of  Death. 

White. 

Colored. 

White. 

Colored. 

Apoplexy 

10.184 
926 
6.722 
3-!79 

70.893 

944 
258 
2.094 
346 
7.771 

18.691 
1.699 

i*-337 
5-834 
130.117 

10.107 

2.762 
22.420 
3.704 
83.203 

Colic           .          

1.529 
7.662 
13.891 
1.074 
26 

79 
1.792 

574 
,  34i 
3.211 

09 

849 
4.766 

202 
07 

°5 
177 

91 
144 
294 

'     2.806 
14.062 

25-495 
1.971 

47 
144 
3.289 
1.053 
625 
5.893 

96 

9.000 
51.029 
2.162 
74 
53 
1.895 

974 
1.541 
3.147 

Diseases  of  the  Heart  

Fits    (Epileptic)     

Fistula  

Gout  

Insanity  .       . 

Influenza  

Liver  Complaint  

Paralysis  

Quinsy  ... 

1.284 
1.500 
367 
•      23.721 

313 
363 

149 

1.681 

2.356 
a-753 
673 
43-537 

3-351 
3.886 
1.695 
17.998 

Scarlet   Fever 

Spitting   of  Blood 

Diseases  of  Urinary  Organs 

Syphilis.. 

3.308 
657 

276 
149 

6.068 

1.207 

2.972 
1-595 

NOTE.— The  blank  spaces  indicate  that  the   diseases  opposite  them  are   rega  ded  as  symttami 
•nerely 


TABLE  SHOWING  THE  COMPARATIVE  MORTALITY  OF  WHITE 
AND  BLACK.  TROOPS  FROM  CONSUMPTION  AT  SEVERAL  OF 
THE  BRITISH  MILITARY  STATIONS,  AS  IT  OCCURS  FROM  YEAR 

TO  YEAR.— (FROM  HAMMOND). 


RATIO    OF    OKA 

I-HS    IN    1,000. 

Station. 

White  Troops. 

Colored  Troops. 

7,r 

IO.1 

6. 

O  7 

8.1 

6. 

6.1 

12  Q 

Ceylon 

4.  Q 

IO  C 

Gibralter 

T*7 

51 

1W.J 

d.1 

•  J 

TABLE  SHOWING  THE  COMPARATIVE  MORTALITY  FROM  MA- 
LARIAL DISEASES,  OF  WHITE  AND  BLACK.  TROOPS,  AT  THE 
SAME  STATIONS,  FROM  1818  TO  1836.— (FROM  HAMMOND.) 


Station. 

White  Troops. 

Colored  Troops. 

IOI.Q 

8.  a 

I  C.Q 

5-6 

81. 

4*4 

410. 

2.4 

1.7 

o.o 

Ceylon  

24.6 

RATIO    OF    DEATHS    TO    I,OOO. 


Note  to  page  22.    (Intemperance.) 

That  intemperance,  using  the  term  in  its  largest  sense,  sometimes 
seems  to  be  hereditary,  is  undeniably  true.  The  morbid  appetite 
seems,  after  long  indulgence,  to  become  a  fixed  constitutional  vice, 
and  as  such  to  be  handed  down  from  father  to  son.  Yet  it  is  fre- 
quently the  case  that  the  children  of  an  intemperate  man,  smarting 
under  the  disgrace  of  having  a  besotted  father,  become,  from  very 
disgust  and  loathing,  the  most  radical  temperance  men  ;  but  tkeir 
children  are  more  than  likely  to  follow  the  course  of  their  grand- 
parent Indeed,  in  intemperate  families,  "  atavism  "  is  a  common 
occurrence,  and  is  explicable  on- the  grounds  above  stated.  When  an 
II 


1 62 

applicant  comes  of  a  family  known  to  have  been  intemperate  for  two 
or  more  generations  past,  his  habits  should  be  most  carefully  scrutin- 
ized by  the  Examiner,  before  recommending  him. 

Note  to  page  23.    (Alcohol,) 

Reformed  inebriates,  unless  after  a  long  interval  of  sobriety,  are 
undesirable  ;  the  long-continued  and  excessive  use  of  alcohol  leaving 
behind  effects  more  or  less  permanent  in  their  nature.  "  The 
characteristic  changes  which  have  been  observed  in  the  brain,  medulla 
oblongata,  etc.,  of  confirmed  drinkers," — writes  Mr.  Anstie — "  con- 
sist essentially  of  a  peculiar  atrophic  modification,  by  which  the  true 
elements  of  nervous  tissue  are  partially  removed,  the  total  mass  of 
nervous  matter  wastes,  serous  fluid  is  effused  into  the  ventricles  and 
the  arachnoid,  while  simultaneously  there  is  a  marked  development 
of  fibrous  tissue,  granular  fat  and  other  elements  which  belong  to  a 
lower  order  of  vitalized  products."  Moreover,  intemperance  is  a 
recognized  cause  of  insanity,  particularly  if  any  hereditary  predispo- 
sition thereto  exists  :  out  of  816  cases  of  insanity,  treated  in  a  well- 
known  eastern  asylum,  55,  or  one  in  about  every  15,  were  directly 
traceable  to  excessive  use  of  alcohol. 

Note  to  page  25,    (Acclimation,) 

The  progeny  of  parents  of  northern  extraction,  born  in  the 
tropics,  even  though  sent  to  a  temperate  zone  early  in  life,  are  often 
questionable  risks.  The  enervating  influences  of  a  tropical  climate 
seems  to  follow  them  through  all  their  lives  ;  seems  indeed,  in  a 
single  generation,  ofttimes  to  so  modify  and  break  down  the  constitu- 
tion, as  to  render  it  incapable  of  long  resisting  the  depressing  influ- 
ences of  a  northern  climate.  This  is  best  exemplified  in  the 
children  of  missionaries,  born  of  parents  who  have  for  several  —  or 
perhaps  many — years  resided  in  the  tropical  missionary  fields,  and 
who  have  been  sent  early  in' life  to  the  United  States  to  be  educated. 
Very  many  such  instances  occur  in  New  England,  from  whence  most 
of  the  missionaries  to  eastern  countries  have,  until  recently,  been 
drawn ;  and  whither  their  children  are  often  sent,  to  be  reared  and 
educated  among  relatives.  Experience  has  fully  demonstrated  the 
fact,  that  these  children  born  in  the  tropics  fall  an  easy  prey  to  con- 
sumption, or  some  one  of  the  more  virulent  zymotic  diseases,  before 


has 


If,  however,  the  period  of  maturity 

and  desira 


seems 


arriving  at  mature  yea 
been  safely  reached  and  pas 
ble  in  other  regards,  the  mere  fact  of  having  been  born  in  the 
tropics  need  not  of  necessity  reject.  But  in  the  general  make- 
up of  the  risk,  it  must  not  be  overlooked,  or  treated  as  an  item  of  no 
importance  in  its  relations  to  longevity. 

Note  to  pages  29  and  115. 

The  ready  return  of  chronic  camp  diarrhoea,  even  after  a  long 
period  of  apparent  perfect  recovery,  suggests  great  caution  ;  it  is, 
however,  true,  that  the  lapse  of  time  diminishes  the  liability  to  a 
return  of  the  disease. 

Within  the  past  year,  camp  diarrhoea  has  in  a  great  measure 
disappeared ;  and,  in  our  own  experience,  cases  applying  for  treat- 
ment have  proved  much  less  obstinate  than  they  were  during  and 
immediately  after  the  war — a  return  to  home  comforts  and  the  habits 
of  civil  life  proving,  in  the  great  majority  of  instances,  sufficient  to 
bring  about  a  perfect  recovery.  Indeed,  we  may  reasonably  expect 
that,  in  a  few  years  hence,  this  fearful  scourge  will  only  be  known 
historically.  But  unless  the  bowels  have  been  in  a  healthy  condition 
for  a  long  period — certainly  not  less  than  a  year — the  risk  should 
be  declined. 
Note  to  pages  32  and  88,  (Consumption,) 

The  well-known  hereditary  character  of  consumption  is  always  to 
be  borne  in  mind ;  but  it  does  not  therefore  follow,  that  every  appli- 
cant, one  of  whose  parents  died  of  consumption,  is  uninsurable. 
The  opinion  seems  to  be  gaining  ground,  especially  in  England, 
that  the  proportion  of  non-hereditary  cases  of  this  disease,  is  much 
larger  than  has  been  supposed.  "  That  the  tuberculous  constitu- 
tion"—  says  Dr.  Aitken — "is  transmitted  from  parent  to  child, 
has  long  been  a  popular  belief,  and  regarded  as  one  of  the  best 
established  points  in  the  etiology  of  the  disease.  Actual  proof,  how- 
ever, has  never  yet  been  afforded  of  the  justness  of  the  general 
conviction.  Out  of  102  phthisical  patients  admitted  into  Brompton 
Hospital,  for  Consumption,  26  per  cent,  came  of  tuberculous  parents, 
"a  circumstance  which  may  be  predicated  of  any  mass  of  individuals 
taken  in  a  hospital  :  namely,  that  26  per  cent,  of  them  are  of  phthis- 
ical parents  'J  On  the  other  hand,  while  the  general  statement  may 


i64 


be  made,  that  some  cases  of  phthisis  may  oe  traced  to  hereditary 
influence,  "  it  is  undoubted  that  much  phthisis  is  in  each  generation 
non-hereditary."  Our  present  limits  do  not  permit  a  lengthy  discus- 
sion of  this  topic :  but  the  following  conclusions  seem  to  the  writer, 
warranted  by  past  experience. 

First.  Where  both  parents  have  died  of  consumption,  the  risk 
should  invariably  be  rejected. 

Secondly.  If  brothers  or  sisters  of  the  applicant  have  died  of  the 
same  disease,  the  risk  is  rendered  less  desirable. 

Thirdly.  A  risk,  otherwise  desirable,  need  not  be  rejected  because 
the  party's  mother  died  of  consumption  ;  but,  if  the  party  has  not 
already  and  safely  passed  the  age  at  or  about  which  the  mother  was 
attacked,  extreme  caution  should  be  exercised  in  the  acceptance  of 
the  risk. 

The  annexed  table  shows  the  ratio  of  deaths  from  consumption 

to  10,000  deaths  from  all  causes,  in  the  several  census  districts  of 
the  United  States  for  the  year  1 860 ;  and  the  same  as  modified  by 
sex.  (Compiled  from  the  Census  Report.) 


DISTRICTS. 

RATIO  TO 
TOTAL  DEATHS. 

RATIO  OF  SEXES. 

MALE. 

FEMALE. 

MALE. 

FEMALE, 

DISTRICT  I.  —  Maine,  New    Hamp- 
shire, Vermont,  Massachusetts,  Rhode 
Island,  Connecticut  and  New  York  
DISTRICT  a.  —  Michigan,  Wisconsin, 

1,922 

J»3*3 
1,700 
1,182 

1,004 
871 
402 

55° 
1,258 

2,419 
1,780 
1,901 
1,4^7 

I»39I 
i,*45 
59i 

583 

1,136 

I  ,OOO 
I.OOO 
1,000 
1,000 

I,OOO 

1,000 
1  ,000 
1,000 

1,000 

1.258 

*»345 

i»«3 

1,207 

i,378 
i,4»* 
i,47<- 
i,  060 

po» 

DISTRICT   3.  —  New  Jersey  and  Penn- 

DISTRICT  4.  —  Ohio,  Indiana,  Illinois, 

DISTRICT  5.  —  Delaware,    Maryland, 
District    of    Columbia,    Virginia    and 
North  Carolina  

DISTRICT  6.  —  Kentucky,  Tennessee 
and  Missouri  

DISTRICT   7.  —  South  Carolina,  Geor- 
gia, Florida  and  Alabama  

DISTRICT  8.  —  Mississippi,  Louisiana, 
Arkansas  and  Texas  

DISTRICT    9.  —  Oregon,     California, 
Dakota,  New  Mexico,  Utah  and  Wash- 

,65 

Note  to  page  32. 

Mere  Nephralgia  should  be  diagnosticated  as  comparatively  unim- 
portant ;  but  it  is  probable  that,  in  the  great  majority  of  instances, 
nephralgia  is  symptomatic  of  the  passage  of  a  calculus — and  is  there- 
fore warrant  for  rejection,  or  at  least  a  suspension  of  judgment. 
Nephralgia  is  also,  occasionally,  the  expression  of  malarial  irritation 
— in  which  case  it  is  no  obstacle  to  insurance. 

Note  to  pages  37  and  ]37,    (Insanity,) 

Probably  in  no  disease,  liable  to  present  itself  to  the  Examiner,  is 
the  hereditary  tendency  more  strongly  or  more  uniformly  marked, 
than  in  insanity.  Out  of  1,654  cases  admitted  into  the  Hartford 
"  Retreat  for  the  Insane,"  304,  or  about  one  in  every  five  cases,  were 
of  hereditary  origin.  Dr.  Aitken  gives  the  ratio  as  "  varying  from 
26  to  69  per  cent."  It  is  also  important  to  bear  in  mind  that  heredi- 
tary insanity  is  prone  to  assume  the  most  hopeless  and  incurable  form 
of  this  disease;  namely  "Melancholia:"  of  fifteen  cases  investigated 
by  the  writer,  all  were  clearly  hereditary.  But  there  is  still  another 
point  to  which  the  attention  of  the  Insurance  Examiner  should  be 
drawn :  namely,  that  the  suicidal  propensity  is  more  strongly  marked 
in  Melancholia  than  in  any  other  form  of  the  disease. 

The  Diagnosis  of  some  forms  of  "delusional"  insanity  is  some- 
times exceedingly  difficult.  The  following  rules,  copied  from  Ait- 
ken,  as  compiled  by  him  from  the  admirable  work  of  Bucknill  & 
Tuke,  are  practically  valuable  : 

(i.)  Learn  as  thoroughly  as  possible  the  antecedents  and  history 
of  the  patient. 

(2.)  Estimate  the  value  of  the  hereditary  tendency,  upon  the  fol- 
lowing principles  :  (A.)  The  insanity  of  one  parent  indicates  a  less 
degree  of  predisposition  than  that  of  a  parent  and  an  uncle  ;  and 
still  less  than  that  of  a  parent  and  a  grand-parent,  or  of  two  parents. 
(B.)  The  insanity  of  a  parent  and  a  grand-parent,  with  an  uncle  or 
an  aunt  in  the  same  line,  may  be  held  to  indicate  even  stronger  pre- 
disposition than  the  insanity  of  both  parents.  (C.)  The  insanity  of 
a  parent  occurring  after  the  birth  of  a  child,  without  predisposition, 
is  Gf  no  value  in  the  formation  of  an  hereditary  tendency.  (E}.)  If 
several  brothers  or  sisters,  older  and  younger  than  the  patient, 


1 66 

[or  applicant,]  have  become  insane,  the  fact  tells  strongly  in  favor  of 
predisposition,  although  neither  parent  nor  grand-parent  may  have 
been  lunatic.  (E.)  The  insanity  of  cousins  cannot  yet  be  deter- 
mined as  worth  anything  in  favor  of  predisposition,  except  in 
corroboration  of  other  and  weightier  facts. 

(3.)  Ascertain  if  there  has  been  any  change  of  habits  or  predis- 
position. 

(4.)  Exercise  the  greatest  tact  and  discretion  in  the  personal  exam- 
ination of  probably  insane  patients. 

(5.)  Observe  any  peculiarities  of  residence  or  dress. 
(6.)  Study  the  appearances,  demeanor,  and  general  conduct  of  the 
patient. 

(7.)  Notice  any  peculiarities  of  bodily  condition ;  [as  emaciation, 
state  of  the  skin,  bowels,  pulse,  tongue,  etc.] 

(8.)  Observe  any  peculiarities  of  gesture,  or  of  countenance. 
As  a  general  rule,  when,  upon  close  examination,  insanity  appears 
to  be  clearly  hereditary — and  especially  if  the  parent  whose  sex 
agrees  with  that  of  the  party  under  examination  became  insane  before 
his  or  her  birth,  the  risk  had  better  be  declined,  even  though  it  may 
be  in  other  respects  desirable. 

Note  to  page  40.    (Palpitation,) 

The  following  list  includes  the  chief  causes  of  palpitation  of  the 
heart,  except  when  dependent  upon  organic  disease  of  the  organ 
itself:  (i.)  Diseases  or  derangements  of  remote  organs,  as  the 
stomach  or  liver.  (2.)  The  use  of  narcotics  or  stimulants,  as  alcohol, 
opium,  or  tobacco.  (3.)  Gouty,  rheumatic  or  malarial  irritation. 
(4,)  Masturbation,  or  excessive  sexual  indulgence.  (5.)  Excessive  or 
prolonged  mental  labor.  (6,)  Hysteria,  disordered  menstruation. 
(7.)  Anaemia  or  leucocythaemia. 

In  the  latter  case  it  will  probably  be  associated  with  cardiac,  as 
well  as  arterial  and  venous  murmurs  ;  the  former  best  heard  over  the 
base  of  the  heart,  and  the  latter  along  the  course  of  the  carotids. 
Whenever  these  are  present,  the  risk  must  be  declined  :  First,  be- 
cause the  anaemia  is  of  itself  sufficient  cause  for  rejection  ;  and,  Sec- 
ondly, because  it  is  impossible  to  distinguish  with  absolute  certainty 
between  the  sounds  caused  by  the  watery  condition  of  the  blood,  and 


i67 

those  caused  by  actual  organic  disea? i.  Palpitation  is  also  occasionally 
associated  with,  and  dependent  upon  spinal  irritation,  "especially  if 
there  is  tenderness  of  the  upper  half  of  the  spine."  When  easily 
excited,  or  long  continued,  it  is  very  liable  to  result  in  organic 
disease  of  the  heart  —  and  is  certainly  indicative  of  some  source  of 
trouble,  which  it  should  be  the  business  of  the  Examiner  to  ferret 
out  and  explain,  before  recommending  the  risk. 

Note  to  page  46,    (Spitting  of  Blood,) 

While  the  expectoration  of  blood  is,  with  great  propriety,  gener- 
ally looked  upon  as  an  insuperable  obstacle  to  insurance,  it  is,  of 
course,  possible  that  a  person,  who  is  exceedingly  desirable  as  an 
insurance  risk,  may  have  sometime  spat  blood  from  the  mouth  ;  for 
example,  the  bloody  expectoration  of  acute  bronchitis,  or  of  pneu- 
monia, by  no  means  precludes  the  idea  of  subsequent  vigorous  health, 
and  therefore  of  insurability — and  justice  to  the  applicant  demands 
that  the  cause  be  carefully  sought  out.  But  whenever  a  doubt  exists, 
that  fact  alone  should  determine  the  rejection  of  the  risk — else  would 
the  examiner  impair  rather  than  increase  the  safety  of  the  company 
employing  him. 

In  insurance  applications,  the  term  "  spitting  of  blood  "  is  of 
course  used  arbitrarily,  else  would  almost  every  applicant  who 
answers  this  question  negatively  perjure  himself.  It  is  intended  to 
ascertain  whether  any  expectoration  of  blood  from  the  lungs  or 
bronchial  tubes,  or  from  any  source  indicative  of  organic  disease  has 
ever  occurred  ;  and  it  is  sometimes  necessary  to  explain  to  the  applicant 
its  scope  and  meaniug.  Every  man  who  has  had  a  tooth  extracted 
must  have  discharged  blood  from  the  mouth,  and  many  other  causes 
equally  trivial  might  give  rise  to  the  same  thing  ;  but  while  this  would, 
of  course,  be  literally  and  undeniably  "  spitting  of  blood,"  it  would 
not  come  within  the  limits  of  the  technical  meaning  of  this  phrase 
as  employed  in  insurance  applications  or  medical  text  works.  It 
would  be  better  if  the  term,  on  account  of  its  loose  and  unmeaning 
phraseology,  and  on  account  of  its  being  so  frequently  and  easily  mis- 
understood, could  be  dropped  entirely,  and  another  of  greater 
accuracy  substituted  for  it 


i68 


The  following  table  is  intended  to  show  the  more  common  and 
dangerous  sources  of  bloody  expectoration,  together  with  their 
prominent  symptoms  and  insurance  significance  : 


•OURCJt. 

DIAGNOSIS. 

CAUSE    AND    SIGNIFICANCE 

NOSE. 

Blood  generally  issues   from 
the   nostrils  ;    sometimes   flows 
backwards,  and  is   coughed  up, 
but   if  the   patient  is   made    to 
lean   forward,  the    blood    flows 
from  the  nostrils,  which  estab- 
lishes the  diagnosis.     The  blood 
can  generally  be  seen   trickling 
down  the  pharynx  5  and  is  not 
usually  florid. 

Causes  are  almost  always  easi- 
ly made  out,  and  are  of  little 
importance  to  the  Insurance 
Examiner. 

MOUTH. 

The    soft,    spongy,    swollen 
state  of  the    gums,  with    blood 
slowly  oozing   from   them,  and 
the  readiness  with   which    they 
bJted    upon    being    touched,    at 
once  indicates  the  source. 

Generally  indicates  an  im- 
poverished condition  of  the 
blood,  as  in  Scorbutus  ;  and 
calls  for  great  caution. 

BRONCHIAL 
TUBES. 

Expectoration  consists  of  mu- 
cus or  muco-pus,  streaked  with 
blood,   not  intimately  and    uni- 
formly mixed  ;  quantity  of  blood 
generally    quite    small  ;     large, 
course  rales  are  easily  heard. 

Acute  or  chronic  bronchitis  j 
foreign  bodies,  or  ulceration  are 
the  common  causes.  Either  of 
these  reject  or  suspend  until 
complete  recovery  takes  place. 

LUNGS. 

Coincident  with  other  signs 
and     symptoms     of     phthisis  ; 
blood  in  considerable  quantity  ; 
florid  ;   generally    "  frothy,"  or 
containing    small    air    bubbles, 
and  intimately  mixed  with  mu- 
co-pus ;   not  coagulated. 

Almost  always  indicative  of 
tubercular  deposit,  and  is  of 
course  an  unqualified  warrant 
for  rejection. 

STOMACH. 

Sense   of  weight  and  uneasi- 
ness in  the  epigastric  region  ;  or 
perhaps    decided     nausea  ;     the 
matter  vomited  consists  of  dark 
grumous    blood,  altered    by  the 
action    of  gastric    juice,    unless 
caused  by  the  opening  of  an  ar- 
tery, by  ulceration  ;   discharges 
of  altered  blood  from  the  bow- 
els }  tenderness  of  epigastrium. 

Caused  by  injuries  —  as  a 
blow  or  kick  ;  by  inflammation 
or  "active  hyperaemia";  by 
ulceration;  by  cancer;  by  irri- 
tant poisons;  by  an  altered 
state  of  the  blood  itself;  or  it 
may  be  vicarious,  as  of  menstru- 
ation. All  but  the  last  must  ot 
course  reject,  and  that  even 
requires  careful  investigation. 

169 

Note  to  page  48  and  123,   (Urine,) 

In  all  cases  where  symptoms  of  obscure  origin  and  doubtful  signifi- 
cance are  present,  the  urine  should  be  carefully  tested  by  the  most 
approved  methods,  and,  if  possible,  examined  microscopically.  Not 
every  Medical  Examiner,  however,  will  be  so  fortunate  as  to  possess  a 
microscope;  but  no  one  need  be  without  a  supply  of  test-tubes  and 
reagents,  or  the  skill  and  knowledge  requisite  for  their  use.  It  is  true, 
however,  that,  in  practice,  cases  will  rarely  come  before  the  Exam- 
iner in  which  an  examination  will  either  be  proper  or  necessary,  and 
it  should  never  be  done  when  it  can  safely  be  avoided  ;  nor  should 
the  Examiner  ever  permit  himself  to  subject  the  applicant  to  the 
trouble  and  annoyance  of  furnishing  him  with  a  specimen  of  his 
urine,  merely  for  the  purpose  of  acquiring  experience  for  himself,  or 
of  impressing  the  company  employing  him  with  exalted  ideas  of  his 
scientific  ability.  Yet  cases  may  and  do  sometimes  arise,  when  im- 
portant interests  are  at  stake,  and  when  it  becomes  the  duty  of  the 
Examiner  to  at  least  make  a  chemical  examination  of  the  urine ;  in 
all  such  cases,  the  matter  should  be  fully  explained  to  the  applicant, 
that  he  may  understand  its  necessity  and  reasonableness.  The  fol- 
lowing table,  compiled  chiefly  from  Da  Costa  and  Golding  Bird, 
shows  the  morbid  elements  most  likely  to  present  themselves  to 
the  Insurance  Examiner,  together  with  the  best  means  for  their 
detection 


MORBID  ELEMENT 


PHYSICAL    CHARACTERS. 


TESTS    AND    REACTIONS. 


ALBUMEN. 


BLOOD. 


Sp.  gr.  varies  from%l,oio  to 
1.025  5  color  light ;  a  precipi- 
tate of  a  light  color  generally 
falls  after  a  few  hours. 


Color  red,  smoky  or  dingy  j 
deposits,  on  standing,  a  brown- 
ish or  coffee  ground  sediment  5 
if  in  large  quantity,  minute 
coagula  may  be  seen  at  the 
bottom  of  the  test  glass. 


Heat  throws  down  a  more 
or  less  abundant  whitish  pre- 
cipitate, which  is  insoluble  in 
acid  ;  Nitric  acid  also  precipi- 
tates the  albumen,  and  heat 
fails  to  re-dissolve  it. 

The  microscope  at  once  re- 
veals the  presence  of  blood 
globules :  Sulph.  acid  changes 
the  urine  to  a  brown  or  reddish 
brown  color,  showing  the  pres- 
ence of  haematin. 


170 


MORBID  ELEMENT 

PHYSICAL    CHARACTERS. 

TESTS    AND    FACTIONS. 

SUGAR. 

Color  light  ;    sp.    gr.   high  ; 
very  peculiar  odor  j  rarely  de- 
posits sediments  ;  contains  large 
excess  of  water. 

Fill   a   test  tube  about  one 
third  full  of  urine  ;  add  a  few 
drops   of  solution  of  sulphate 
of  copper,  or  just  sufficient  to 
color  the  urine  a  light  tinge  of 
blue  j     add    liquor   potassae    in 
large  excess;   the  mixture  now 
assumes    a  deep  blue  color  if 
sugar  be  present,  and  upon  be- 
ing heated,  it  changes  first  to  a 
brownish   color,   then   yellow, 
and    finally    a    reddish    brown 
precipitate  of  sub-oxide  of  cop- 
per falls  to  the  bottom,  which 
establishes     the     presence     of 
sugar. 

PUS. 

When  the  urine  contains  pus, 
it  deposits  an  opaque,   creamy 
sediment,  or  a  gelatinous  mass,  is 
generally   alkaline   and  always 
slightly  albuminous. 

Upon  microscopic  examina- 
tion, pus  cells  are  readily  dis- 
covered ;  a  drop  of  acetic  acid 
should  be  added  to  the  speci- 
men under  examination  for  the 
purpose  of  developing  the  nu- 
clei.    The   chemical   test     for 
pus    is    liquor  potassae,  which 
forms    therewith  a    gelatinous 
precipitate    of    a    light    straw 
color. 

BILE. 

Color  very  dark  j  sp.  gr.  not 
materially    changed  ;  generally 
coincident    with    other   symp- 
toms of  hepatic  derangement. 

Pour  a  small    quantity   of 
urine  on  a  white  plate,  or  other 
porcelain  surface  ;    a  drop    of 
nitric  acid   is    then   added  $ 
play  of  color  shortly  takes  place 
commencing  with   green    an 
blue,  passing  to  violet  and  red, 
and  often  finally  to  yellow  and 
brown. 

MUCUS. 

Color  light  ;  a  more  or  less 
abundant      flocculent      deposit 
takes        place  ;        putrefactive 
changes  com  nence   very  early, 
the     urine       apidly    becoming 
ammo  liacal. 

Upon  the  addition  of  acetic 
acid,    the    fluid     part    of    the 
mucus  coagulates  into  a  thin 
semi-opaque,  corrugated  mem- 
brane,  which   at    once   estab- 
lishes  the  difference    between 
mucus  and  pus. 

flotetopage  76,    (Pulse,) 

The  rapidity  of  the  heart's  action  is  considerably  modified  b)  the 
position  of  the  body ;  possibly  to  a  greater  extent  than  is  comm  >nly 
supposed.  This  subject  has  been  carefully  studied  by  Dr.  Guy,  and 
with  the  following  results :  In  100  healthy  males,  averaging  27  yearj 
of  age,  in  a  state  of  rest,  and  of  freedom  from  excitement,  the  aver- 
age frequency  of  the  pulse  was,  when  standing,  79  ;  when  sitting,  70 ; 
and  when  lying,  67  beats  per  minute; — or  a  difference  of  9  beats 
between  sitting  and  standing.  In  50  healthy  females,  of  the  same 
mean  age,  and  under  the  same  circumstances  in  other  regards,  the 
average  pulse  when  standing,  was  89  ;  when  sitting,  81  ;  and  when 
lying,  80  beats  per  minute ;  — or  a  difference  of  8  beats  between  stand- 
ing and  sitting. 

In  my  own  examinations,  I  have  generally  found  a  difference  of 
from  4  to  8  beats  per  minute,  between  the  standing  and  sitting  posi- 
tions ;  and  a  difference  of  less  than  6  beats  is  the  rare  exception. 
Yet  the  difference  is  very  frequently  stated,  in  the  reports  of  Exam- 
iners, as  being  no  more  than  one  or  two  beats  —  which  is,  at  best, 
but  a  very  unskillful  "  guess,"  and  of  no  value  whatever  to  the  com- 
pany. The  pulse  should  be  counted  zfull  half  minute,  by  the  watch, 
in  both  positions,  and  the  result  should  be  carefully  noted  down  at 
the  time. 

But  to  the  Insurance  Examiner,  the  pulse  is,  in  general,  little  more 
than  an  indication  of  the  condition  of  the  nervous  system  at  the  time 
of  the  examination.  The  mere  fact  that  they  arc  being  examined  is 
sufficient,  with  many  people,  to  cause  a  marked  acceleration  of  the 
heart's  action,  or  even  to  produce  violent  palpitation.  It  is  often  the 
case  that  the  applicant  has  walked  rapidly  from  his  place  of  business 
to  the  office  of  the  Examiner,  in  which  case  he  is  almost  certain  to 
present  an  unusually  rapid  pulse.  Many  an  excellent  risk  has  been 
needlessly  rejected,  on  account  of  an  unusual  rapidity  of  pulse,  which 
probably  subsided  before  the  applicant  reached  his  own  home.  And 
this  is  an  act  of  injustice  to  both  company  and  applicant.  In  all  cases 
in  which  the  pulse  is  merely  rapid,  without  symptoms  of  cardiac  or 
other  organic  disease,  the  party  should  be  allowed  to  sit  until  the 
heart  shall  have  had  time  to  resume  its  normal  action ;  or  if  this  fail* 


172 

?f  accomplish  rg  the  object  he  shouk  be  re-examined  on  a  subse- 
quent occasion,  after  having  learned  by  experience,  that  an  examin- 
ation for  life  insurance  is  not  the  fearful  ordeal  his  imagination  may 
have  pictured  it.  I  have  frequently  found  it  necessary,  in  my  own 
experience,  to  make  seveial  examinations,  and  have  even  found  some 
applicants  so  exceedingly  "  nervous "  that  I  have  been  obliged  to 
resort  to  the  strategy  of  amusing  them  for  awhile,  by  cheerful  con- 
versation or  otherwise,  before  getting  at  the  real  character  of  the 
heart's  action,  and  have  thcrcb)  received  some  most  desirable  risks 
which  must  otherwise  have  been  rejected;  and  this  is  precisely  the 
experience  &  many  Medical  Examiners.  In  fact,  the  pulse  is  very 
like  an  unreliable  witness :  it  must  be  sharply  "  cross-examined," 
before  full  credence  is  given  to  its  testimony. 

Note  to  page  127.    ( Locomotor  Ataxy, ) 

It  is  by  no  means  impossible  that  cases  of  Locomotor  Ataxy,  in  its 
incipient  stage,  may  present  themselves  to  the  Medical  Examiner, 
and  its  early  detection  is  both  very  important  and  very  difficult.  The 
symptom  first  complained  of  is  generally  pain,  or  rather  pains.  The 
patient  generally  supposes  himself  to  be  troubled  with  rheumatism 
or  neuralgia  ;  and  careful  inquiry  will  often  develop  the  fact  that  he 
has  been  repeatedly  "  doctored  "  for  one  or  the  other  or  both  of  these 
diseases.  But  the  anomalous  character  of  these  pains  ought  always 
to  arouse  the  suspicions  of  the  alert  Examiner;  the  party  describes 
them  as  "boring,"  or  "stabbing,"  or  "cutting,*'  or  "shooting" 
pains,  and  ofttimes  seems  vainly  to  rack  his  brain  in  search  of  a  word 
of  sufficient  force  and  intensity  to  express  his  meaning  ;  they  are 
generally  aggravated  by  sudden  changes  of  temperature  —  especially 
by  cold,  damp  weather;  they  seldom  last  longer  than  from  a  lew 
seconds  to  a  minute,  but  are  liable  to  recur  at  very  brief  intervals — 
sometimes  as  often  as  "ten,  fifteen  or  twenty  times  an  hour;"  they 
•re  limited  to  no  particular  part  of  the  body,  though  rather  more 
likely  to  affect  the  lower  extremities  than  otherwise.  "Often  a  first 
sign  is  reeling  about  upon  getting  out  of  bed  in  the  dark."  At  this 
stage,  even,  while  the  party  admits  no  deterioration  of  his  general 
health,  careful  observation  will  often  detect  defective  co-ordination: 
if  he  is  made  to  walk  with  his  eyes  closed,  the  gait  will  become 


173 

unsteady  and  staggering.  Nocturnal  incontinence  ot  mine,  and  noc- 
turnal emissions  of  semen  are  also  premonitory  symptoms  of  loco- 
motor  ataxy ;  though  these  are  less  constant  than  the  peculiar  pains 
and  uncertainty  of  locomotion  above  alluded  to.  But  when  these 
symptoms  are  present,  the  risk  should  be  unhesitatingly  declined, 
and  the  existence  of  any  one  of  them  suggests  great  caution,  and 
probably  a  suspension  of  judgment. 

Note  to  page  129,    (Vertigo.) 

Some  companies  inquire  as  to  previous  attacks  of  vertigo  (dizzi- 
ness). This  is  a  mere  symptom,  and  its  true  character  is  usually 
misapprehended.  It  is  safe  to  say  that  it  is  ordinarily  but  an  evidence 
of  dyspeptic  derangement.  It  is  not  a  precursory  symptom  of  apo- 
plexy, paralysis,  or  organic  diseases  of  the  nervous  centre  of  any  sort. 
(FLINT.)  It  is  not  an  evidence  of  disease  of  the  heart  even.  It  is 
sometimes  evidence  of  "  nervous  asthenia,"  but  under  such  circum- 
stances concurrent  symptoms  will  readily  determine  the  true  char- 
acter of  the  case.  So  also  it  may  occur  from  sexual  excesses,  or  the 
inordinate  use  of  tobacco — cessation  from  the  use  of  narcotics  or 
stimulants,  etc.  Taken  alone,  its  previous  occurrence  can  scarcely 
be  considered  of  sufficient  importance  to  materially  impair  the  risk. 

Note  to  page  134.    ( Softening  of  the  Brain.) 

It  is  unfortunately  the  case  that  we  have  no  symptom  or  group  of 
symptoms  which  are  pathognomonic  of  softening  of  the  brain  in  its 
early  stages — -the  only  time  at  which  it  is  at  all  liable  to  come  before 
the  Examiner ;  and  this  fact  gives  an  additional  importance  to  the 
disease,  in  its  relation  to  life  insurance. 

In  the  first  place,  softening  of  the  brain  occurs  most  frequently  in 
those  persons  whose  health  has  been  for  some  time  more  or  less 
impaired  without  any  assignable  cause  being  apparent;  the  symptoms 
complained  of  are  vague  and  unmeaning,  being  indicative  of  general 
debility  or  diminished  vital  power,  rather  than  of  any  organic  dis- 
ease ;  in  another  class  of  cases,  some  "  distinct  chronic  and  exhaust- 
ing disease  may  be  present" — but  such  cases  will  rarely  or  never 
come  before  the  Insurance  Examiner,  the  evidences  of  disease  being 
sufficiently  marked  to  attract  the  attention  of  the  .solicitor.  The 
following  remarks  are  intended  to  apply  only  to  those  cases  which 


174 

•re  "  developed  slowly  and  insidiously,"  and  which  are  not  preceded 
by  inflammation,  hemorrhage,  or  acute  ramollissement ;  in  fact  to  cases 
of  "chronic  idiopathic  ramollissement,"  and  to  these,  even,  only  in 
their  earliest  stages.  In  the  great  majority  of  instances,  the  symp- 
tom first  attracting  attention,  is  a  "torpor  and  prostration  of  intellect." 
The  patient  himself  is  generally  aware  that  his  powers  of  mind  are 
gradually  becoming  weaker  and  weaker  ;  he  finds  himself  unable  to 
attend  to  his  business  —  or  at  least  to  do  so  costs  him  a  constant  and 
painful  effort ;  tasks  which  have  seemed  to  him  but  trifles  heretofore, 
now  assume  immense  proportions ;  and  he  especially  laments  his 
inability  to  undertake  and  successfully  prosecute  any  task  requiring 
sustained  mental  effort.  Sometimes  a  sudden  inability  to  prosecute 
some  employment  requiring  unusual  perfection  of  motor  power  first 
excites  the  patient's  alarm ;  for  example,  a  flutist  of  celebrity,  fifteen 
months  prior  to  the  manifestation  of  any  marked  symptoms  of  cerebral 
disease,  became  suddenly  unable  to  "  finger  "  and  blow  his  instru- 
ment with  his  accustomed  skill,  and  this  turned  out  to  be  a  typical 
case  of  softening  of  the  brain.  "Softening  of  the  cerebral  hemis- 
pheres," says  Andral,  "induces  alteration  in  motion  much  more  con- 
stantly than  in  intelligence ;"  but  this  rule  is  certainly  not  without 
its  sxceptions ;  for  it  is  by  no  means  unfrequently  the  case  that  mem- 
ory, or  the  power  of  retaining  mental  impressions  and  recalling  them 
at  will,  is  one  of  the  early  —  indeed  the  earliest — symptoms  of  cere- 
bral softening.  Occasionally  the  patient  notices  a  slight  impairment 
of  the  power  of  controlling  the  muscles  of  the  lips  and  tongue,  or 
perhaps  of  the  cheeks  and  lips,  or  of  the  tongue  alone  ;  he  is  sur- 
prised to  find  that  he  cannot  eject  his  saliva  with  certainty  and 
accuracy,  or  that  he  cannot  fix  his  lips  as  in  the  act  of  whistling;  his 
tongue  becomes  slightly  tremulous,  and  when  protruded  turns  slightly 
to  one  side.  Another  very  important  symptom,  sometimes  observed, 
is  an  unaccountable  inability  to  write  as  well  as  usual  ;  the  patient 
cannot  form  letters,  or  guide  his  pen  with  accuracy  ;  he  complains 
that  "his  hand  trembles,"  and  calls  the  attention  of  his  friends  to  the 
fact,  and  to  his  inability  to  account  for  it ;  words  are  sometimes  spelt 
wrong,  or  one  word  substituted  for  another,  or  the  patient  some- 
times writes  and  dispatches  to  distant  friends,  letters  which  are  but 


ihe  merest  muddle  of  nonsense  —  and  yet,  at  this  very  time,  he  may 
converse  rationally  and  coherently,  and  even  attend  to  plain,  simple 
matters  of  business.  Among  the  prodromic  symptoms  of  softening, 
may  also  be  mentioned  headache,  "usually  dull  in  character,"  numb- 
ness, obscure  pain,  weight  or  indescribable  sensation  of  "something 
wrong,"  in  the  extremities,  a  stooping  gait,  and  tendency  to  cramp  in 
the  limbs.  When  an  applicant  admits  the  presence  of  these  symp- 
toms  or  of  any  one  of  them  ;  and  especially  when  to  this  is  super 
added  a  general  appearance  of  debility,  let  the  risk  be  unqualifiedly 
rejected. 
Note  to  page  144,  ( Female  applicants, ) 

Extreme  longevity  is  but  rarely  reached  by  women ;  yet  the  average 
duration  of  life  among  women  is  longer  than  among  men,  probably 
because  they  are  less  exposed  to  causes  of  mortality — and  this  even, 
with  the  perils  incident  to  maternity  added  to  other  causes.  In  fact 
other  things  being  equal,  the  woman  who  is  happily  a  wife  ana 
mother  is  far  preferable,  as  an  insurance  risk,  to  the  unfortunate 
spinster,  upon  whom  age  and  decrepitude  are  only  too  certain  to 
creep  prematurely. 

The  following  tables  are   self-explaining,  and  therefore  require 
no  comment: 

TABLE    SHOWING   THE    COMPARATIVE    MORTALITY   OF    FIRST 

AND  SUBSEQUENT  LABORS. 


Authority. 

No.  of 
Primi- 
pircB. 

No.  of 
Deaths. 

Or  one  in 
every 

No.  of 
Multi- 
pirce. 

No.  of 
Deaths. 

Or  one 
in  every 

Hardy  &  McClintock 
Matthews  Duncan.  .  . 
Johnson  &  Sinclair.. 

2,125 
3-722 

4.535 

35 
50 
83 

60 
74 
54 

4-510 
12,671 

9.213 

30 
103 
80 

150 
123 
«5 

Totals  

10  382 

168 

62 

^Uo94 

213 

124 

I76 


SHOWING  THE  MORTALITY   FROM  PUERPERAL    FEVER    IN    DIP- 
FERENT  PREGNANCIES.— (MATTHEWS  DUNCAN.) 


No.   of  Pregnancy. 

No.  of 
Mothers. 

No.  of 
Deaths. 

Percentage 
of   Deaths. 

Or  on«  in 

a.aci 

07 

4.  -70 

2-1 

4-  Oil 

8< 

2.  1  1 

47 

Fifth  to  Ninth     

i,<6* 

47 

7   OI 

^•7 

*_  

189 

9 

3       i 

4.76 

11 

SHOWING    THE    RELATIVE  LONGEVITY    OF    MARRIED  AND  UN- 
MARRIED   FEMALES. 


At  the  age  of— 

A  married  female  i 
live  — 
Years.                  Mo 
4O. 

as  to 

nths. 
•4 

0 

An  unmarried  female  has 
to  live  — 
Tears                   Months. 
,0  8 

Difference. 

Tears.      Mo  i 
9  8 

16..., 

6 

5  6 

Is  

3  6 

28 

II 

•  7 

•  26  

A 

35  

25  

*3  

5 

a  a 

From  the  "Insurance  Guide  and  Hand  Book." 

Symptoms  referable  to  Tobacco, 

Medical  examiners,  especially  in  the  United  States,  will  meet 
with  many  cases  presenting  symptoms  of  somewhat  obscure  origin, 
which  may  without  doubt,  be  fairly  attributed  to  the  excessive  use  of 
tobacco.  It  is  peculiarly  prone  to  disturb  the  heart's  action,  render- 
ing its  contractions  weak  and  uncertain,  and  even,  in  some  instances, 
producing  marked  irregularity  of  its  rythm.  A  noticeable  feature  in 
such  cases,  is,  that  the  most  trifling  causes  will  sometimes  bring  on 
violent  attacks  of  palpitation ;  a  few  minutes  of  rapid  walking ; 
climbing  several  pairs  of  stairs  hastily  ;  the  presence  in  the  stomach 
of  indigestible  articles  of  food  ;  any  sudden  mental  excitement,  even 
though  trivial  in  its  nature,  and  a  variety  of  equally  simple  and 
unimportant  causes,  are  often  sufficient  to  provoke  severe  attacks  of 
palpitation,  which  may  also  prove  quite  obstinate,  "According  to 
the  experiments  of  Sir  Benj.  Brodie,  tobacco  causes  paralysis  of  the 
heart,  through  the  medium  of  the  nerves  " —  and  this  conclusion  gives 
additional  importance  to  the  facts  above  detailed  in  their  relation  to 
insurance.  Mr.  Lizars  gives  an  account  of  an  excessive  smoker  who 
was  subject  to  terribly  severe  attacks  of  mgina  pectoris ;  after  an 


unusually  severe  and  prolonged  attack,  which  came  near  proving  ratal, 
he  abandoned  smoking  altogether,  and  the  disease  disappeared  without 
any  treatment.  Severe  dyspepsia  is  a  very  frequent  result  of  using 
tobacco,  and  is  in  general  very  obstinate  when  dependent  upon  thii 
cause  ;  obstinate  constipation  is  another  of  its  evil  results  ;  from  these 
two  evils  result  emaciation  and  general  debility,  laying  the  foundation 
for  various  nervous  diseases.  A  disorder  very  much  resembling 
delirium  tremens  was  several  times  witnessed  by  the  late  Dr.  Chap- 
man, and  by  him  attributed  to  this  potent  agent ;  the  patients  recov- 
ered on  abandoning  their  pipes.  In  the  reports  of  nearly  ever) 
Insane  Asylum  in  the  United  States,  may  be  found  several  cases  of 
insanity  charged  to  the  account  of  tobacco.  In  the  form  of  snuff 
it  sometimes  becomes  poisonous,  on  account  of  being  contaminated 
with  lead  during  the  process  of  manufacture  —  thus  producing  lead 
colic  or  lead  palsy.  It  would  be  easy  to  extend  this  list  of  symptoms 
to  very  much  greater  length,  but  sufficient  has  already  been  said  to 
indicate  its  more  general  and  prominent  effects. 

Does  the  use  of  tobacco  tend,  materially,  to  shorten  life  ?  Candid, 
unprejudiced  observations  on  this  point  are  very  much  needed.  As 
yet  we  have  no  data  upon  which  to  found  an  opinion  —  much  less 
to  base  a  statement  of  facts.  Several  American  "  Counterblasts  "  have 
been  launched  against  this  persecuted  weed ;  each  as  valueless  ana 
impotent  as  that  of  the  Royal  fop  of  England  ;  the  clergy,  the  press 
and  the  medical  profession,  have  severally  waged  war  against  tobacco, 
and  yet  it  remains  and  will  remain  the  delight  of  millions. 

There  can  be  no  doubt  that  an  excessive  use  of  tobacco — espec- 
ially by  a  person  of  feeble  constitution — does  tend,  materially,  to 
shorten  life.  Moreover,  a  person  whose  blood  is  already  poisoned 
by  nicotine,  is  thereby  rendered  less  capable  of  surviving  severe 
attacks  of  acute  diseases,  and  this  is  a  proper  matter  for  the  examiner 
to  consider.  Severe  and  obstinate  dyspepsia,  angina  pectoris,  or  oft- 
recurring  palpitation  —  especially  if  they  exist  in  persons  excessively 
addicted  to  the  use  of  tobacco  —  demand  rejection.  For,  even  if  it 
cannot  be  clearly  shown  that  tobacco  is  the  underlying  cause,  its  use 
most  assuredly  adds  one  more  element  of  danger  in  the  ca<»e,  and  one 
much  more  likely  to  remain  permanently,  than  to  be  removed  by  a 
resolute  effort  on  the  part  of  the  applicant. 


INDEX. 


Artists  ..*•••••••••••••••«»••••••••••••••••   1 6 

Artisans 16 

Age 18,  73 

Acclimation 25 

Army  Employment 28 

Asthma 29,  83 

Apoplexy 29,  131 

Ancestors  Longevity 56 

Answers  of  Applicant 64 

Appearance,  General 69 

Aspect  of  Countenance 70 

Age,  Apparent 73 

Aphonia 83 

Aneurism  of  Heart 101 

Aneurisms 1 08 

Angina  Pectoris 101 

Adhesions,  Heart I  o  I 

Atrophy,  Heart 101 

Aortic  Obstruction 105 

Aortic  Regurgitation 105 

Abdominal  Organs 109 

Atrophy  of  Liver 112 

Atrophy  of  Mucous  Membrane 116 

Albuminuria ..119 

Addison's  Disease 123 

Atrophy  of  Brain 133 

Asthenia,  Nervous 136 

Abscesses... 


143 

Amputations 54,  146 

B 

Bronchitis 31 

Bones,  Size  of. gi 

Bilious  Temperament 74 

Blood  Murmurs 107 

Blood  Vessels,  Disease  of. 108 

flright's  Disease n<j 

Brain,  Disease  of. 130 

Brain  Chron.  Poisoning 136 

Blanks,  Filling  up  of. 150 


Climate  ........•••••••••••••••••••••••••••   t  jj 

Consumption 32 

Cholic 32 

Cardiac  Diseases 33 

Chorea 37 

Catarrh 42 

Cough,  Habitual 53 

Chest  Measurement 67 

Complexion 71 

Color  of  Hair  and  Eyes 71 

Congestion  of  Lungs.. 84 

Cyanosis 102 

Congestion,  Liver Ill 

Cirrhosis  of  Liver 1 12 

Calculus 122 

Cystitis,  Chronic 122 

Cerebro-Nervous  System 124 

Convulsions 126 

Co-ordination,  Defective 127 

Coup  de  Soliel 135 

Cutaneous  Affections 143 

Climacteric,  Female 145 

Constitution 147 

Cachexia 149 

Certificates,   Duplicates 151 


Diseases,  Previous 29 

Dropsy 33 

Diptheria 34 

Dyspepsia 51 

Dysentery 52 

Diarrnoea 52,  114 

Disease  within  Seven  Year* 55 

Dyspnoea 85 

Deposits,  Pulmonary.. ~  85 

Deposits,  Signs  of  Pulmonarj 86-88 

Degenerations,  Heart....... ...,.loa 

Dilatation,  Heart 1O> 


179 


i8o 


FNDEX. 


Page. 

Degenerations,  Liver 112 

Digestion,  Importance  of. 116 

Diabetes 122 

Duchenne's  Disease 126 

Deposits,  Brain 133 

Delirium  Tremens 22, 137 

Diathesis 148 


Employment,   Previous..... 29 

Eyes 72 

Emphysema 89 

Empyaemia 91 

Epilepsy 36, 126 

Encephalitis 130 


Fistula 34 

Fits 36,  126 

Friend,  Reference  to 62 

Furunculi 143 

Female  Applicants 144 

G 

Gout 37 

Gonorrhoea 49 

Growths,  Intracranial 133 

H 

Heart  Disease 33,  93,  101 

Hernia..... 43,  144 

Haemoptysis 46 

Haematemesis 47 

Hereditary  Disease 18,  59,  138 

Height 66 

Hair 


71 

Hydrothorax 91 

Heart — Signs  of  Disease  : 

Location 94 

Bulging  or  Depression 94 

Impulse 94 

Area  of  Dullness 95 

Pulsation 96 

Sounds 98 

Location  of  Sounds 100 

Non-organic  Disease  of. 106 

Hypertrophy,  Heart 102 

Hepatitis,  Chronic 113 

Haemorrhoids 116 

Hysteria 36, 126 

Hypertrophy  of  Brain 133 

Hip  Disease 144 

I 

Intemperance 22,  136 

Insanity 37,  130,  137 

Injury,  Traumatic 34 


Insurance,  Previous 63 

Identity  of  Applicant 65 

Idiosyncrasy 76 

Inspection •••••...  80 

Intestinal  Tube 114 

Intellection,  Derangement 130 


Jaundice. 
Joints — 


J 


•  39 
144 


K 

Kidneys,  Disease  of. 118 

"         Enlargement  of. 118 


Life  Expectation 19 

Liver,  Disease  of. 38,  ill 

Longevity  of  Ancestors 56 

M 

Mechanics 1 6 

Marriage 20 

Muscles,  Contour  of,  etc 72 

Mensuration 78 

Movements,  Respiratory 80 

Malformations,  Heart 103 

Myocarditis 103 

Mitral  Regurgitation, 105 

"       Obstruction 105 

Motion,  Derangement  of. 125 

Menstrual  Functions 145 

Metritis,  etc 146 

N 

Name 15 

Nervous  Temperament 74 

Neuralgia,  Intercostal 92 

Nutrition 117 

Nephritis,  Chronic 118 

Nephralgia Il8 

Nervous  Asthenia 136 


Occupation 15 

Opium  Eating 23 


Professional  Men 16 

Paralysis 40,  128,  142 

Palpitation 40 

Parents,  Living  or  Dead,  etc 58 

Physician,  Family 61 

Phlegmatic  Temperament 74 

Pulse J^ 

Pneumothorax 91 

Pleurodynia 9' 


INDEX. 


181 


Page. 

Pericarditis 103 

Pancreas "3 

Prostate,  Enlarged 122 

Poisoning  of  Brain 136 

Pregnancy  and  Parturition 144 

Phlegmasis  Dolens 146 


Quinsy. 


40 


Residence 15 

Residence,  Foreign 25 

Rheumatism 41,  51 

Rupture 43 

Rejection,  Previous 63 

Respiratory  Organs 78 

Respiratory  Organs,  Diseases  of. 82 

Rigidity  of  Muscles 1*8 

Ramollissement,  Brain 134 

Ramollissement,  Spinal  Cord 142 

Risk,  General  Character 14? 


Sobriety ^l 

Scarlatina 45 

Spitting  of  Blood 46 

Syphilis.- 49 

Stricture.; 49.  *i2 

71 


Pigt 

Sanguine  Temperament 73 

Stomach 1 1 1 

Spleen 114 

Sensation,  Derang.  of. 129 

Spasms 126 

Softening  of  Brain 134 

Softening  of  Spinal  Cord* 142 

Sunstroke 135 

Spinal  Diseases ...141 

Senses  Special,  Loss 144 


Temperance 21 

Temperament 73,  147 

Tumors,  Intrathoracic... 92 

Tremor 125 

Tumors...  1A4 

«••••.••••••••••••••••••  **t*f 

u 

Urinary  Organs,  Disease  of. 47 

Ulcers 143 


Vaccination....  24 

Valvular  Changes,  Heart- 104 

Varicose  Veins... 1 43 


w 


Weight.. 


INDEX    TO   APPENDIX. 


Page. 

Acclimation 162 

Alcohol,  Effects  of. 162 

Applicants,  Female 175 

orain,  Softening  of. 173 

Blood,  Spitting  of. 167 

Consumption ...163 

Clergyman's  Sore  Throat 154 

Colored  Races,  Mortality  of .....160,  161 

Diarrhoea,   Camp 163 

Females,  Longevity  of« 176 

Insanity M 165 

Intemperance 161 

Inebriates,  Safety  of. 162 

Locomotor  Ataxy ......172 

Labor,  Mortality  from... 175 


Page. 

Mortality,  Tables  of. 157,  158 

Mortality,  from  various  Diseases.-...  156 

Nephralgia       ...» 165 

Occupation,  Effects  of. .151 

Public  Speakers,  Safety  of. 154 

Professional  Men 154 

Physicians 154 

Puerperal  Fever,  Mortality  from 176 

Palpitation 166 

Pulse 171 

Sexes,  Mortality  of. 159 

Teachers 154 

Tobacco,  Effects  of..i 176 

Urine,  Examination  of. 169 

Vertigo ...  ..173 


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